Johnson v. SSA

Filing 5

MEMORANDUM AND ORDER re: 2 ORDERED that plaintiff shall have fifteen (15) daysfrom the date of this Order to pay the statutory filing fee of $350.00, or to submit a fully completed CJA Form 23 (financial affidavit). FURTHER ORDERED that if plaintiff fails to comply with this Order, the case shall be dismissed, without prejudice and without further notice. Response to Court due by 2/12/2013.. Signed by District Judge Henry E. Autrey on 1/28/13. (Attachments: # 1 CJA Form 23)(CEL)

FINANCIAL AFFIDAVIT

CJA 23
(REV. 5/98)

IN SUPPORT OF REQUEST FOR ATTORNEY, EXPERT OR OTHER COURT SERVICE WITHOUT PAYMENT OF FEE
IN UNITED STATES

MAGISTRATE

DISTRICT

IN THE CASE Of:

APPEALS COURT or

OTHER PANEL (Specify below)
LOCATION NUMBER

FOR
VS

AT

DOCKET NUMBERS

PERSON REPRESENTED (Show your full name)

1
2

Probation Violator

5

Parole Violator

6

Habeas Petitioner

7

2255 Petitioner

8

Misdemeanor

Appellant

4

Felony

Defendant - Juvenile

3

CHARGE/OFFENSE (describe if applicable & check box - )

Defendant - Adult

Material Witness

9

Magistrate

District Court

Court of Appeals

(Specify)

ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY
Are you now employed?

No

Yes

Am Self Employed

Name and address of employer:
IF YES, how much do you
EMPLOYearn per month? $
MENT
If married is your Spouse employed?
IF YES, how much does your
Spouse earn per month? $

IF NO, give month and year of last employment
How much did you earn per month? $

Yes

No
If a minor under age 21, what is your Parents or
Guardian's approximate monthly income? $

Have you received within the past 12 months any income from a business, profession or other form of self-employment, or in the
form of rent payments, interest, dividends, retirement or annuity payments, or other sources?
Yes
No

ASSETS

OTHER
INCOME

CASH

RECEIVED

SOURCES

IF YES, GIVE THE AMOUNT
RECEIVED & IDENTIFY $
THE SOURCES
Have you any cash on hand or money in savings or checking account

Yes

No IF YES, state total amount $

Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household
Yes
No
furnishings and clothing)?

PROPERTY

VALUE

DESCRIPTION

IF YES, GIVE THE VALUE AND $
DESCRIBE IT

MARITAL STATUS
SINGLE

DEPENDENTS

Total
No. of
Dependents

List persons you actually support and your relationship to them

MARRIED
WIDOWED
SEPARATED OR
DIVORCED
APARTMENT
OR HOME:

OBLIGATIONS D E B T S &
MONTHLY
& DEBTS

Creditors

Total Debt

Monthly Payt.

BILLS

(LIST ALL CREDITORS,
INCLUDING BANKS,
LOAN COMPANIES
CHARGE ACCOUNTS,
ETC. )

$
$
$

$

$

$

I certify under penalty of perjury that the foregoing is true and correct. Executed on (date)
SIGNATURE OF DEFENDANT
(OR PERSON REPRESENTED)

$
$