Paupers Affidavit

OCCAOnline Rules of the Court of Criminal Appeals Form 13.3 Pauper's Affidavit IN THE DISTRICT COURT OF __________ COUNTY STATE OF OKLAHOMA STATE OF OKLAHOMA, Plaintiff, vs. Case No. _________________ _________________________, Defendant. PAUPER'S AFFIDAVIT I, (Name)_________________________, (Soc.Sec.#)______________________________, (Address)___________________________________________________________________, upon oath, do depose and state: I. PERSONS IN HOUSEHOLD Spouse: Children: Others: Is Person a Dependent ____________________________________ _____ ____________________________________ _____ ____________________________________ _____ ____________________________________ _____ Are you claimed as a dependent by parent or guardian? Yes( ) No( ) Yes( ) No( ) Yes( ) No( ) Yes( ) No( ) Yes( ) No( ) If so, explain: __________________________________________________ ________________________________________________________________ II. FINANCIAL STATUS--ASSETS (Defendant or person(s) responsible for defendant's support): 2000 © American LegalNet, Inc. A. 1. Cash on Hand: $ _________________________ 2. Bank Accounts: Bank Name Account # Checking/Savings $ Amount /Address ________________________________________________________________ ________________________________________________________________ 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.) ________________________________________________________________ Home and Other Real Estate: Balance Owed Real Property Value _______________________________________________________________________ Vehicle(s): Description Value Balance Owed _______________________________________________________________________ _______________________________________________________________________ Personal Property: (furniture, appliances, tools, equipment, etc.) Items Market Value Balance Owed _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Litigation you or your spouse have pending for recovery of money: Case No. County _______________________________________________________________________ FINANCIAL STATUS--LIABILITIES Charge or Open Accounts: Description Balance _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Housepayment or Rent: Mortgagee/Landlord Monthly Payment _______________________________________________________________________ If own, balance:________________________________________________________ Child Support Obligations Monthly Payment:_____________________________________________________ C. D. E. F. III. A. B. C. 2000 © American LegalNet, Inc. D. Other Debts: Creditor Balance _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ IV. OTHER A. Have you transferred or sold any assets since charges were filed in this case? B. If so, describe the buyer and the amount received: _______________________________________________________________________ _______________________________________________________________________ Have you retained counsel in this case or in any other pending criminal case? Yes( ) No( ) C. D. Yes( ) No( ) If so, state the case number, court, attorney and amount paid to attorney for services: _______________________________________________________________________ _______________________________________________________________________ If you have posted bond, who provided the funds for the bond? _______________________________________________________________________ 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( ) 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. E. _________________________ Applicant's Signature Subscribed and sworn to before me this __________ day of __________ 19__________. State of Oklahoma County of _________________ COURT CLERK OR _________________________________ Notary Public By: _________________________ Deputy My Commission Expires_________ 2000 © American LegalNet, Inc.