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)__________________________________, (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? If so, explain: Yes( ) No( ) _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ II. FINANCIAL STATUS--ASSETS (Defendant or person(s) responsible for defendant's support): 1 American LegalNet, Inc. www.FormsWorkFlow.com 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.) __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 2 American LegalNet, Inc. www.FormsWorkFlow.com 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. A. FINANCIAL STATUS--LIABILITIES Charge or Open Accounts: Description Balance __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ B. Housepayment or Rent: Mortgagee/Landlord Monthly Payment __________________________________________________________________________ If own, balance:_____________________________________________________________ C Child Support Obligations 3 American LegalNet, Inc. www.FormsWorkFlow.com Monthly Payment:___________________________________________________________ D Other Debts: Creditor Balance __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ IV. OTHER A. Have you transferred or sold any assets since charges were filed in this case? If so, describe the buyer and the amount received: __________________________________________________________________________ ___________________________________________________________________________ Yes( ) No( ) 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? ___________________________________________________________________________ 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( ) D. E.