Form 13.17a Affidavit Regarding Ability to Pay
IN THE DISTRICT COURT OF ___________ COUNTY
STATE OF OKLAHOMA
STATE OF OKLAHOMA, v. ___________________________,
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Case Nos.: __________________ __________________ __________________ __________________ __________________ __________________
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AFFIDAVIT REGARDING ABILITY TO PAY
[This affidavit and any supporting documents shall not be visible on a court-controlled website. 22 O.S. § 983(I).
If you need additional space on any questions, please use page 5 or attach additional pages.]
GOVERNMENT BENEFITS
Do you receive (circle all that apply):
SNAP (food stamps)
WIC |
TANF |
SSI |
SSDI |
Tribal Disability |
Veterans Disability |
Section 8 (Housing Choice Voucher) |
Other housing assistance (be specific): ______________________________________________________________________
Other federal need-based support (be specific): _______________________________________________________________
Proof is attached for the following programs: __________________________________________________________________
INCOME
Do not list any disability or other government benefits listed above.
Number of adults in household: ____ Number of children that you support: ___
Defendant |
Adult 2 |
Adult 3 |
Adult 4 | |
Relationship to you: |
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Income source: (employment, gift, etc.) |
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Do you support this person? |
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If you support adults in your household, explain why you must support them:
______________________________________________________________________________
Are you currently employed? Yes / No How long employed/unemployed? _____________
Highest Grade/Degree completed: _____________
In the past ten (10) years, what was your longest term of employment? (employer/job title/how long)
______________________________________________________________________________
Are you currently still doing that type of work? Yes / No
If no, describe any barriers preventing you from going back to that type of work:
______________________________________________________________________________
Do you have any physical or mental health conditions that make it difficult for you to work or manage your money? If yes, describe:
______________________________________________________________________________
______________________________________________________________________________
List any other reasons you would like the judge to know about why it is difficult for you to earn enough income to pay your fines/fees off:
______________________________________________________________________________
______________________________________________________________________________
EXPENSES
List your expenses. The Court may ask you to provide proof of these expenses, so bring proof with you to your cost hearing.
Expense: |
Amount: |
Last time late (or amount behind): |
Expense: |
Amount: |
Last time late (or amount behind): |
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Utilities (Water/Phone/Power) |
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Medical Bills Insurance/Prescriptions |
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List any additional expenses:
_____________________________________________________________________________
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Do you pay child support? Yes / No If so, how much per month? ________
Are you behind on child support? Yes / No If so, how much? ______
Do you have to pay any other expenses on these cases (restitution, DA fees, probation fees, drug test fees)? If yes, please describe.
_____________________________________________________________________________
_____________________________________________________________________________
When was the last time you had difficulty paying for food? What did you do?
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When was the last time you had difficulty paying for housing? What did you do?
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ASSETS
Do you own the following:
Your Home: Yes / No
Investments (stocks/bonds): Yes / No Other land/homes: Yes / No More than one vehicle: Yes / No (Car, truck, motorcycle, Boat, ATV, etc.) |
The land your home is on: Yes / No
Vehicle: Yes / No (With Loan Yes / No)
Bank Accounts: Yes/No Value: ______
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If you answered "Yes" to any of the answers in the box above, please describe this property:
______________________________________________________________________________
______________________________________________________________________________
List any additional expenses:
_____________________________________________________________________________
_____________________________________________________________________________
When was the last time you had to sell or pawn something to pay for an expense? Describe what happened.
______________________________________________________________________________
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OTHER INFORMATION
Is there a definite date when your financial situation will improve or worsen? (For example, you will start working on X date, your disability payments will start on X date, or you will lose your housing on X date.) If yes, please describe.
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If someone can verify your financial situation, please attach a letter from that person. For example, a case manager at a shelter, a clergy member who provides you with assistance, etc.
I declare under penalty of perjury under the laws of Oklahoma that the foregoing is true and correct to the best of my knowledge and belief.
Date:_____________________ Respectfully submitted,
Respectfully submitted, ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ |
Additional information:
[ ] Attached ____________________________________
[ ] Not Attached Phone
ADDITIONAL INFORMATION
Use this page if you need additional space to respond to any question. Attach additional pages if needed. Please indicate which section you are responding to (e.g. Benefits, Income, Expenses, Assets, Other).
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