Fill and Sign the Oklahoma Decree Form

IN THE DISTRICT COURT OF COUNTY STATE OF OKLAHOMA __________________________________________________ Plaintiff, Case No. v. __________________________________________________ Defendant, FINANCIAL AFFIDAVIT (Post-Decree) 43 O.S. § 118 IN COMPLETING THIS FORM, YOU ARE NOT REQUIRED TO PROVIDE ANY INFORMATION FROM A DATE EARLIER THAN THE DATE OF THE LAST DECREE/ORDER ENTERED IN THIS CASE THAT MODIFIED CHILD SUPPORT. 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. Names of child(ren) who is/are the subject to child support payment: ________________________________________________________________________________ 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) TOTAL GROSS MONTHLY INCOME $ $ YOU MUST DISCLOSE ALL GROSS INCOME (12 O.S. 1170). IF REQUIRED TO DO SO BY 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 THE 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) Only: $_________________ Names of Dependent(s) currently covered: ____________________________________________________________ *** Child Care: Projected annual child care costs for the next twelve (12) months: MONTHLY PROJECTED CHILD CARE 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 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 74 Revised 9/05