Form 133 Pauper's Affidavit

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) , (Soc.Sec.#) ,

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

I. PERSONS IN HOUSEHOLD

Spouse: Is Person a Dependent Yes No

Children: Is Person a Dependent Yes No

           Is Person a Dependent Yes No

Others: Is Person a Dependent Yes No

         Is Person a Dependent Yes No

         Is Person a Dependent Yes No

         Is Person a Dependent Yes No

         Is Person a Dependent Yes No

         Is Person a Dependent 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 Account # Checking/Savings $ Amount

Account # Checking/Savings $ Amount

3. Bonds & Securities

Description Value

Value

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

Description Value

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

Value Balance Owed

E.

Personal Property: (furniture, appliances, tools, equipment, etc.)

Items Market Value Balance Owed

Market Value Balance Owed

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

Balance

Balance

B.

House payment or Rent:

Mortgagee/Landlord Monthly Payment

If own, balance:

C.

Child Support Obligations

Monthly Payment:

D.

Other Debts:

Creditor Balance

Balance

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.