IN THE DISTRICT COURT OF __________ COUNTY STATE OF OKLAHOMA _________________________, Plaintiff, vs. _________________________, Defendant. Case No. ______________________________ PRISONER'S AFFIDAVIT OF INABILITY TO PAY Name ___________________________ Prisoner Identification No. ______________________________ Address______________________________________________________________________________ I, _____________________________, upon oath, do depose and state: (your name) I. PERSONS IN HOUSEHOLD Is Person a Dependent? Name of Spouse: __________________________________________ Yes ( ) No ( ) Name(s) of Children: _______________________________________ Yes ( ) No ( ) _______________________________________ Yes ( ) No ( ) Name of Others: _______________________________________ Yes ( ) No ( ) Are you claimed as a dependent by parent or guardian? Yes ( ) No ( ) If so, explain: __________________________________________________ II. FINANCIAL STATUS--ASSETS (Inmate, Inmate's spouse or person(s) responsible for defendant's support): A. INCOME OF INMATE: Employer's name, address and telephone number: _________________________________ ______________________________________________________________________________ $_________ Gross weekly wages $_________ Net weekly wages Employer of Inmate's spouse or person(s) responsible for defendant's support address and telephone number: _______________________________________________________________________ ______________________________________________________________________________ $_________ Gross weekly wages $_________ Net weekly wages B. MONEY ­ ITEMS OF VALUE 1. Cash on Hand: $ _________________________ 2. Bank Accounts: Bank Name/Address /Account #/Checking/Savings/Money Markets _____________________________________________________________________________________________ _____________________________________________________________________________________________ State the amount or value of each account $__________________________________________________ 3. Stocks, Bonds & Securities: Description___________________________________________________ Value $_________________ 4. All Other Possessions of Value: (including tax refunds, notes, accts. receivable, retirement accounts, gifts, etc.) Description___________________________________________________________________________ Value of each $________________________________________________________________________ 1 American LegalNet, Inc. www.FormsWorkFlow.com C. HOME AND OTHER REAL ESTATE: Home: Own ( ) Rent ( ) Real Property Address: ___________________________________________ Value $_________ Balance Owed $____________ Monthly House Payment or Rent $______ Name of Landlord or Mortgage Company __________________ Other Real Property Address(es): _________________________________________________________ Value $ _________ Balance Owed $____________ Mineral Interests You Own or Have an Interest In __________________Value $_________ D. Vehicle(s): Description Value Balance Owed _____________________________________________________________________________________ E. Personal Property: (furniture, appliances, tools, equipment, etc.) Description Value Balance Owed _____________________________________________________________________________________ F. Litigation you or your spouse have pending for recovery of money: Case No. County _____________________________________________________________________________________ III. FINANCIAL STATUS--LIABILITIES A. Credit Card/Charge or Open Accounts: Description Balance _____________________________________________________________________________________ B. Child Support Obligations Monthly Payment: _____________________________________________________________________ C. Other Debts: Creditor Balance _____________________________________________________________________________________ IV. OTHER Have you transferred or sold any assets (real or personal) in the last twelve months? Yes ( ) No ( ) If so, describe the buyer and the amount received: ____________________________________________ V. FILING FEES Do you have any friends or relatives who are able/willing to assist you or pay the filing fee? Yes ( )No ( ). If Yes, have those persons been asked to help you? Yes ( ) No ( ). VI. MONEY IN THE PRISONER/ INMATE(S) TRUST ACCOUNTS PURSUANT TO 57 O.S. 2011 §566.3, THE PRISONER MUST FILE A CERTIFIED COPY OF THE PRISONER'S TRUST ACCOUNT RECORDS WITH THE COURT THAT REFLECTS THE BALANCE AND ACTIVITY OF THE PREVIOUS SIX (6) MONTHS AT THE TIME THE PETITION IS FILED. IF THE PRISONER IS ON PROBATION OR PAROLE, THE PRISONER WILL FILE CERTIFIED COPIES OF BANK OR SAVINGS STATEMENTS OF THE ACCOUNT AND INCOME RECEIPTS FOR THE PRIOR SIX (6) MONTHS. A COURT ORDER IS NOT REQUIRED FOR THE A PRISONER TO OBTAIN CERTIFIED COPIES OF ACCOUNT INFORMATION. I am unable to pay the court costs at this time. I verify that the statements made in this affidavit are true and correct. Dated this ______ day of _______________, 20___. _____________________________________________ PRISONER'S Signature 2 American LegalNet, Inc. www.FormsWorkFlow.com