Caption
The United States District Court district, the Register No., the U.S. Court Docket No., and In the Matter of Statement of, with a box for Parolee or Mandatory Releasee.
CJA 22
Statement of Parolee or Mandatory Releasee Concerning Appointment of Counsel Under the Criminal Justice Act
- Agency
- U.S. Courts
- Revision
- 09/76
- Fillable fields
- 26
- Pages
- 1
- Official source
- U.S. Courts form page
- Checked
- October 20, 2026
CJA 22: Statement of Parolee or Mandatory Releasee Concerning Appointment of Counsel
CJA 22, Statement of Parolee or Mandatory Releasee Concerning Appointment of Counsel Under the Criminal Justice Act, is a one-page form captioned for a United States District Court. The U.S. Courts list it under CJA Forms. The PDF prints the edition (9/76), and the U.S. Courts page lists it as effective on September 1, 1976.
The statement concerns a matter before the United States Parole Commission. The person signing states that they have been advised of the charges and their rights in an attached Notice of Pending Dispositional Review, Warrant Application or Summons to Appear, and that they understand they may apply to the United States District Court for appointment of counsel. The form says that representation will be furnished if the judicial officer determines they are financially unable to obtain attorney representation. The person then either declines to apply, or applies and states their financial condition.
This page explains the form in plain words and is not legal advice. You can fill it out free in your browser on this page and download the result without an account.
What's on CJA 22
Statement of rights
The person's name and which document is attached: a Notice of Pending Dispositional Review, a Warrant Application or a Summons to Appear.
Choices 1 and 2
Choice 1 says the person does not wish to apply to the District Court for appointment of counsel. Choice 2 applies for appointment of counsel and states the person's financial condition.
Financial condition
Employed or unemployed, weekly income if employed, average weekly income if self-employed, cash on hand and in bank, number of dependants, and property owned.
Signatures and warning
The applicant's signature certifying the above to be correct, the witness's signature and title, the date, and a warning that a false or dishonest answer may be punishable under 18 U.S.C. § 1001.
How to fill out CJA 22
- 1
Fill in the caption
Enter the district, the Register No. and the U.S. Court Docket No., and check Parolee or Mandatory Releasee.
- 2
Name the attached document
Write the person's name in the statement and check which document is attached: Notice of Pending Dispositional Review, Warrant Application or Summons to Appear.
- 3
Mark one choice
Mark choice 1 to not apply to the District Court for appointment of counsel, or choice 2 to apply.
- 4
List the financial details
With choice 2, the form asks whether the person is employed, weekly income, cash on hand and in bank, number of dependants and property owned.
- 5
Sign and date
The applicant signs under "I certify the above to be correct." The form also has lines for a witness's signature and title, and a date.
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Court, fees and warning
Court
The form is captioned for a United States District Court, and an application under choice 2 is made to the District Court for appointment of counsel.
Fees
The form does not print a fee.
False answers
The form says a false or dishonest answer to a question in this application may be punishable by fine or imprisonment or both (18 U.S.C. § 1001).
Edition
The PDF prints the edition (9/76). The U.S. Courts page lists the form as effective on September 1, 1976.
Related forms
CJA 23
Financial Affidavit
71 fields, 1 page
CJA 20
Appointment of and Authority to Pay Court-Appointed Counsel
149 fields, 1 page
CJA 7
Order Terminating Appointment of Counsel and/or Authorization for Distribution of Available Private Funds
25 fields, 1 page
CJA 19
Notice to Court-Appointed Counsel of Public Disclosure of Attorney Fee Information
2 fields, 1 page
Who uses CJA 22?
The form names who signs it and who decides on appointment of counsel.
Official sources and the blank
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Questions about Form CJA 22
Who signs CJA 22?
The parolee or mandatory releasee signs as applicant, certifying the information is correct. The form also has lines for a witness's signature and title.
What does CJA 22 have to do with the Parole Commission?
The form says the person may apply to the United States District Court for appointment of counsel to assist or represent them in the matter before the United States Parole Commission.
Can CJA 22 be used to decline counsel?
Choice 1 on the form says the person does not wish to apply to the District Court for appointment of counsel.
What financial information does CJA 22 ask for?
Whether the person is employed or unemployed, weekly income if employed, average weekly income if self-employed, cash on hand and in bank, number of dependants, and property owned.
Who decides whether counsel is appointed?
The form says representation by counsel will be furnished if the judicial officer determines the person is financially unable to obtain attorney representation.
What warning does CJA 22 print?
It says a false or dishonest answer to a question in the application may be punishable by fine or imprisonment or both, citing 18 U.S.C. § 1001.