OCCA

Form 13.3 Pauper's Affidavit

IN THE DISTRICT COURT OF ___________________ COUNTY
STATE OF OKLAHOMA

STATE OF OKLAHOMA, Plaintiff,

vs.

___________________________________, Defendant.

Case No. __________________

PAUPER'S AFFIDAVIT

I, (Name)__________________________________, (Last four digits of Soc.Sec.#)__________,

(Address)________________________________________________________________, upon oath, do depose and state:

I. PERSONS IN HOUSEHOLD

Is Person a Dependent

Spouse:
Children:

Others:

______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________

______________________________________________________

Yes( ) No( )
Yes( ) No( )
Yes( ) No( )
Yes( ) No( )

Yes( ) No( )

Are you claimed as a dependent by parent or guardian?

Yes( ) No( )

If so, explain: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________

II. FINANCIAL STATUS--ASSETS (Defendant or person(s) responsible for defendant's support):

A.

1. Cash on Hand: $ _________________________
2. Bank Accounts:
Bank Name/Address        Last four digits of Account #       Checking/Savings       $ Amount
______________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. Bonds & Securities
Description                                                                                            Value
______________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. All Other Possessions of Value: (including tax refunds, notes, accts. receivable, etc.)
Description                                                                                           Value
______________________________________________________________________________________________________________________________________________________________________________________________________________________________

B.

1. Current Employment: __________________________________________________________________________
____________________________________________________________________________________________________________________________________________________
2. Earnings: __________________________________________________________________________
____________________________________________________________________________________________________________________________________________________
3. If not currently employed, last employment:
Place & Date: __________________________________________________________________________
____________________________________________________________________________________________________________________________________________________
4. Supplemental Income: (V.A., Soc. Security, Disability, Child Support, etc.) ______________________________________________________________________________________________________________________________________________________________________________________________________________________________

C.

Home and Other Real Estate:
Real Property                                                     Value                                 Balance Owed
______________________________________________________________________________________________________________________________________________________________________________________________________________________________

D.

Vehicle(s):
Description                                                         Value                                Balance Owed
____________________________________________________________________________________________________________________________________________________
__________________________________________________________________________

E.

Personal Property: (furniture, appliances, tools, equipment, etc.)
Items                                                                  Market Value                    Balance Owed
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

F.

Litigation you or your spouse have pending for recovery of money:
Case No.                                                            County
__________________________________________________________________________

III.

FINANCIAL STATUS--LIABILITIES

A.

Charge or Open Accounts:
Description                                                         Balance
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

B.

Housepayment or Rent:
Mortgagee/Landlord                                            Monthly Payment
__________________________________________________________________________
If own, balance:_____________________________________________________________

C

Child Support Obligations
Monthly Payment:___________________________________________________________

D

Other Debts:
Creditor                                                                 Balance
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

IV. OTHER

A.

Have you transferred or sold any assets since charges were filed in this case?      Yes( ) No( )

If so, describe the buyer and the amount received:
__________________________________________________________________________
___________________________________________________________________________

B.

Have you retained counsel in this case or in any other pending criminal case?       Yes( ) No( )

If so, state the case number, court, attorney and amount paid to attorney for services:
___________________________________________________________________________
___________________________________________________________________________

C.

If you have posted bond, who provided the funds for the bond?
___________________________________________________________________________

D.

Do you have any friends or relatives who are able and willing to assist you in hiring counsel and paying for transcripts?                                                                                        Yes( ) No( )

If so, have those persons been asked to help?                                                         Yes( ) No( )

E.

If a friend or relative has given previous financial assistance in this case, including the posting of bond, but is no longer able or willing to do so, an affidavit to that effect from that person shall be attached, stating why such help is no longer available.

I further swear and affirm that I am without funds or other sources of income to pay an attorney or to pay for transcripts and costs associated with this case. I understand I am under a continuing obligation to keep this Court informed of any changes in my financial status and this Court may conduct another hearing to determine my indigent status at any time.

____________________________________
Applicant's Signature

Subscribed and sworn to before me this __________ day of ___________________ 20_______.

State of Oklahoma
County of ______________________     OR

_____________________________________
Notary Public

My Commission Expires__________________

COURT CLERK

By: _________________________
      Deputy

Updated in accordance with 2016 OK CR 20.

A.	1. Cash on Hand: $ _________________________ 2. Bank Accounts: Bank Name/Address Last four digits of Account # Checking/Savings $ Amount ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ 3. Bonds & Securities Description Value ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ 4. All Other Possessions of Value: (including tax refunds, notes, accts. receivable, etc.) Description Value ______________________________________________________________________________________________________________________________________________________________________________________________________________________________
B.	1. Current Employment: __________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________ 2. Earnings: __________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________ 3. If not currently employed, last employment: Place & Date: __________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________ 4. Supplemental Income: (V.A., Soc. Security, Disability, Child Support, etc.) ______________________________________________________________________________________________________________________________________________________________________________________________________________________________
C.	Home and Other Real Estate: Real Property Value Balance Owed ______________________________________________________________________________________________________________________________________________________________________________________________________________________________
D.	Vehicle(s): Description Value Balance Owed ____________________________________________________________________________________________________________________________________________________ __________________________________________________________________________
E.	Personal Property: (furniture, appliances, tools, equipment, etc.) Items Market Value Balance Owed __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________
F.	Litigation you or your spouse have pending for recovery of money: Case No. County __________________________________________________________________________
III.	FINANCIAL STATUS--LIABILITIES
A.	Charge or Open Accounts: Description Balance __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________
B.	Housepayment or Rent: Mortgagee/Landlord Monthly Payment __________________________________________________________________________ If own, balance:_____________________________________________________________
C	Child Support Obligations Monthly Payment:___________________________________________________________
D	Other Debts: Creditor Balance __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________

A.	Have you transferred or sold any assets since charges were filed in this case? Yes( ) No( ) If so, describe the buyer and the amount received: __________________________________________________________________________ ___________________________________________________________________________
B.	Have you retained counsel in this case or in any other pending criminal case? Yes( ) No( ) If so, state the case number, court, attorney and amount paid to attorney for services: ___________________________________________________________________________ ___________________________________________________________________________
C.	If you have posted bond, who provided the funds for the bond? ___________________________________________________________________________
D.	Do you have any friends or relatives who are able and willing to assist you in hiring counsel and paying for transcripts? Yes( ) No( ) If so, have those persons been asked to help? Yes( ) No( )
E.	If a friend or relative has given previous financial assistance in this case, including the posting of bond, but is no longer able or willing to do so, an affidavit to that effect from that person shall be attached, stating why such help is no longer available.


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