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IN THE DISTRICT COURT OF COUNTY STATE OF OKLAHOMA ______________________________________________ Plaintiff, Case No. v. ______________________________________________ Defendant, FINANCIAL AFFIDAVIT (PRE-DECREE) 43 O.S. § 118 This document is filed by father/mother (Circle one) FATHER: MOTHER: ADDRESS: ADDRESS: CITY, STATE, ZIP CITY, STATE, ZIP SOC SEC NO: SOC SEC NO: OCCUPATION: OCCUPATION: PRIMARY EMPLOYER: PRIMARY EMPLOYER: BIRTHDATE: BIRTHDATE: If you claim to be a victim of domestic abuse, or claim other good cause, you are not required to disclose your address unless ordered by the Court. Relationship to child(ren) subject to this action:__________________________________________ Child(ren) who is/are the subject of this action: FIRST MIDDLE LAST Date of Birth Month Day Year Social Security Number PRIMARY EMPLOYER NAME: ______________________________________________________________________ PRIMARY EMPLOYER ADDRESS: ___________________________________________________________________ Street, City, State, Zip Code PRIMARY EMPLOYER TELEPHONE: ________________________________________________________________ AVERAGE NUMBER OF HOURS WORKED PER WEEK: ______________________________________________ CIRCLE THE BASIS ON WHICH YOUR PAY IS BASED : HOURLY; WEEKLY; MONTHLY; ANNUALLY AND INDICATE WHAT YOUR PAY IS FOR THE CIRCLED AMOUNT: $_____________________________________. CIRCLE HOW OFTEN YOU ARE PAID: WEEKLY; EVERY 2 WEEKS; TWICE MONTHLY; MONTHLY; HOW LONG HAVE YOU WORKED FOR THIS EMPLOYER:_____________________________________________ SECONDARY EMPLOYER NAME: ________________________________________________________________ SECONDARY EMPLOYER ADDRESS: _____________________________________________________________ Street, City, State, Zip Code SECONDARY EMPLOYER TELEPHONE: ___________________________________________________________ CIRCLE THE BASIS ON WHICH YOUR PAY IS BASED : HOURLY; WEEKLY; MONTHLY; ANNUALLY AND INDICATE WHAT YOUR PAY IS FOR THE CIRCLED AMOUNT: $_______________________________________ CIRCLE HOW OFTEN YOU ARE PAID: WEEKLY; EVERY 2 WEEKS; TWICE MONTHLY; MONTHLY HOW LONG HAVE YOU WORKED FOR THIS EMPLOYER: _______________________________________________ IF REQUIRED TO DO SO BY THE DISCOVERY CODE; COURT RULE; COURT ORDER IN THIS CASE, PLEASE ATTACH COPIES OF YOUR LAST FOUR (4) PAY STUBS FROM YOUR PRIMARY AND SECONDARY EMPLOYMENT. INCOME / EXPENSES / ASSETS AND LIABILITIES: GROSS MONTHLY INCOME FATHER MOTHER Salary Wages Commissions Dividends Bonuses Severance Pay Pensions Rent Interest Income Trust Income Annuities Social Security Benefits Workers' Compensation Benefits Unemployment Insurance Benefits Disability Insurance Benefits Gifts Prizes All other sources (Specify) GROSS MONTHLY INCOME $ $ YOU MUST DISCLOSE ALL GROSS INCOME (12 O.S. § 1170) IF YOU ARE REQUIRED TO DO SO BY THE DISCOVERY CODE; COURT RULE; COURT ORDER IN THIS CASE, PLEASE INDICATE IF YOU FILED TAX RETURNS FOR THE LAST THREE YEARS: YES/NO (CIRCLE ONE). IF REQUIRED TO DO SO BY THE DISCOVERY CODE; COURT RULE; COURT ORDER IN THIS CASE, ATTACH COPIES OF YOUR FEDERAL AND STATE INCOME TAX RETURNS FOR THE LAST THREE (3) YEARS INCLUDING ALL SCHEDULES AND ATTACHMENTS. COPIES SHOULD BE PROVIDED TO THE OTHER PARTY IN THE CASE OR HIS/HER ATTORNEY AND THE COURT. DID YOU OR THE OTHER PARTY IN THIS CASE RECEIVE THE EARNED INCOME TAX CREDIT FOR ANY OF THE PAST THREE TAX YEARS _________YES _________NO (CHECK ONE). DEDUCTIONS PER PAY PERIOD: Itemize pay period deductions from gross income: FATHER MOTHER State income taxes Federal income taxes Number of exemptions taken FICA Income Assignment Withholding Union or other dues Retirement or pension fund Savings plan Medical Insurance Dental Insurance Life Insurance Other Other deductions Other deductions Other deductions Credit Union (specify whether for savings or loan payment) TOTAL PAY PERIOD DEDUCTIONS FROM GROSS INCOME $ $ NET PAY PERIOD INCOME (TAKE HOME PAY) $ $ OTHER: FATHER MOTHER Monthly court-ordered child support paid in other cases* Court-ordered visitation travel related expenses Regular medical expenses of the children not covered by insurance *REQUIRED INFORMATION ON PAY-PERIOD COURT-ORDERED CHILD SUPPORT (ATTACH COPIES OF COURT ORDER (S) AND PROOF OF AMOUNTS PAID FOR THE PAST SIX (6) MONTHS. ** REQUIRED INFORMATION ON MEDICAL INSURANCE PREMIUM: Provider/Name of Plan: _____________________________________________________________________________ Address: _________________________________________________________________________________________ Street, City, State, Zip Code Phone number: ____________________________________________________________________________________ Policy Number: ____________________________________________________________________________________ Total Premium: $_________________ Premium for Employee Only: $_________________ Premium for Employee and Dependants: $_________________ Premium for Child(ren): $___________________ Debts: CREDITOR'S NAME PURPOSE FOR DEBT DATE PAYABLE BALANCE MONTHLY PAYMENT TOTAL $ $ PROPERTY WITH A VALUE OF ONE HUNDRED DOLLARS ($100.00) OR MORE: If either party claims a property item as their separate property put an F or M beside the description of the property. All property of the parties known to me owned individually or jointly (indicate who holds or how title held: (F) Father, (M) Mother, Or (J) Jointly). Where space is insufficient for complete information or listing please attach separate schedule. VALUE OWED THEREON (a) Household furnishings, appliances, and equipment (b) Automobiles (Year-Make) (c) Securities - stocks bonds (d) Cash and Deposit Accounts (banks, Ravings loans, credit unions - savings and checking) : Life Insurance: Name & Address of Company Policy No. Face Amount Cash Value Accumulated Div. Or Loan Amount Profit Sharing, 401K or Retirement Accounts-Interest and Amount: Presently Vested Name: $ $ Name: $ $ Other Personal Property and Assets (Specify with value): Real Estate (Where more than one parcel of real estate owned, attach sheet with identical information for all additional property): Address Type of Property Original Cost Date of Acquisition Mtg. Balance Taxes Equity Other Liens Basis of Valuation Total Present Market Value Legal Description (a separate sheet may be used) Business Interest (indicate name, share, type of business, present market value less indebtedness, name of creditor, balance due, equity value): ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Other Assets (Specify): ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ *** Child Care: Projected annual child care costs for the next twelve (12) months: MONTHLY PROJECTED CHILDCARE COSTS JAN $______ FEB $_______ MAR $_______ APR $_______ MAY $_______ JUN $_______ JUL $_______ AUG $______ SEP $_______ OCT $_______ NOV $_______ DEC $_______ $________________ divided by 12 = $____________________ Total Cost Average Monthly Cost NAMES OF CHILDREN IN CHILD CARE: _______________________________________________________________ NAME OF CHILD CARE PROVIDER: _______________________________________________________________ ADDRESS OF CHILD CARE PROVIDER: _______________________________________________________________ Street, City, State, Zip Code VERIFICATION STATE OF OKLAHOMA ) ) SS. COUNTY OF ______________ ) _______________________________________ of lawful age, being first duly sworn, that I am the (Plaintiff/Defendant) named in the above Financial Affidavit and I declare the statements contained herein are true and correct. ____________________________________ Party’s Signature Subscribed and sworn to me, a notary public within and for said County and State, on this _______ day of __________________________, _______. ____________________________________ NOTARY PUBLIC My Commission Expires: _____________________________ Firm Name: _____________________________ by: _____________________________ Attorney’s Signature Attorney Name: _____________________________ (Please print or type) Bar Number: _____________________________ Address: _____________________________ Street _____________________________ City, State, Zip Telephone Number: _____________________________ FAX Number: _____________________________ AOC Form 75 Revised 9/05