Form 13.17a Affidavit Regarding Ability to Pay

IN THE DISTRICT COURT OF ___________ COUNTY

STATE OF OKLAHOMA

 

STATE OF OKLAHOMA,
Plaintiff,

v.

___________________________,
Defendant.

 

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Case Nos.:

__________________

__________________

__________________

__________________

__________________

__________________

 

 

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:
(spouse, parent, etc.)


Yourself


_______________


_______________


_______________


Income Amount:


_______________


_______________


_______________


_______________

Income source:

(employment, gift, etc.)


_______________


_______________


_______________


_______________


How often? (week/month)


_______________


_______________


_______________


_______________

Do you support this person?


Yes


_______________


_______________


_______________

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):


Rent/Mortgage


__________


_______________


_______________


__________


_______________

Utilities (Water/Phone/Power)


__________


_______________


_______________


__________


_______________


Car payment


__________


_______________


_______________


__________


_______________


Insurance


__________


_______________


_______________


__________


_______________


Child care/expenses


__________


_______________


_______________


__________


_______________

Medical Bills Insurance/Prescriptions


__________


_______________


_______________


__________


_______________

List any additional expenses:

_____________________________________________________________________________

_____________________________________________________________________________

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?

_____________________________________________________________________________

_____________________________________________________________________________

When was the last time you had difficulty paying for housing? What did you do?

_____________________________________________________________________________

_____________________________________________________________________________

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: ______

_

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.

______________________________________________________________________________

______________________________________________________________________________

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.

______________________________________________________________________________

______________________________________________________________________________

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,

____________________________________
Signature

____________________________________
Name

____________________________________

____________________________________
Address

____________________________________
Phone

 

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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