Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Financial Affidavit Pre Decree Form. This is a Oklahoma form and can be use in District Court Statewide.
Loading PDF...
Tags: Financial Affidavit Pre Decree, 75, Oklahoma Statewide, District Court
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
American LegalNet, Inc.
www.USCourtForms.com
PRIMARY EMPLOYER NAME: ______________________________________________________________________
PRIMARY EMPLOYER ADDRESS: ___________________________________________________________________
Street,
City,
State,
Zip Code
PRIMARY EMPLOYER TELEPHONE: ________________________________________________________________
AVERAGE NUMBER OF HOURS WORKED PER WEEK: ______________________________________________
HOURLY; WEEKLY; MONTHLY; ANNUALLY AND
CIRCLE THE BASIS ON WHICH YOUR PAY IS BASED:
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: ___________________________________________________________
HOURLY; WEEKLY; MONTHLY; ANNUALLY AND
CIRCLE THE BASIS ON WHICH YOUR PAY IS BASED:
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
American LegalNet, Inc.
www.USCourtForms.com
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
American LegalNet, Inc.
www.USCourtForms.com
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)
$
$
FATHER
MOTHER
OTHER:
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:
American LegalNet, Inc.
www.USCourtForms.com
CREDITOR'S NAME
PURPOSE
FOR DEBT
DATE
PAYABLE
MONTHLY
PAYMENT
BALANCE
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) :
American LegalNet, Inc.
www.USCourtForms.com
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
American LegalNet, Inc.
www.USCourtForms.com
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
American LegalNet, Inc.
www.USCourtForms.com
VERIFICATION
STATE OF OKLAHOMA
COUNTY OF ______________
)
) SS.
)
_______________________________________ 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
American LegalNet, Inc.
www.USCourtForms.com