Form 13.17a. Affidavit Regarding Ability to Pay
Oklahoma Statutes AnnotatedTitle 22. Criminal ProcedureEffective: November 8, 2023
Effective: November 8, 2023
T. 22, Ch. 18, App., Form 13.17a
Form 13.17a. Affidavit Regarding Ability to Pay
IN THE DISTRICT COURT OF __________ COUNTY STATE OF OKLAHOMA
STATE OF OKLAHOMA, | ) | Case Nos.: |
Plaintiff, | ) | |||
) | ||||
v. | ) | |||
) | ||||
, | ) | |||
Defendant. | ) | |||
[This affidavit and any supporting documents shall not be visible on a court-controlled website. 22 O.S. § 983(1). If you need additional space on any questions, please use page 5 or attach additional pages.]
GOVERNMENT BENEFITS
Do you receive (circle all that apply):
SNAP (food stamps)
WIC TANF SSI SSDI
Tribal Disability Veterans Disability Section 8 (Housing Choice Voucher)
Other housing assistance (be specific):
Other federal need-based support (be specific):
Proof is attached for the following programs:
INCOME
Do not list any disability or other government benefits listed above.
Number of adults in household: _____ Number of children that you support: _____
Defendant | Adult 2 | Adult 3 | Adult 4 | ||
Relationship to you: (spouse, parent, etc.) | Yourself | ||||
Income Amount: | |||||
Income source: (employment, gift, etc.) | |||||
How often? (week/month) | |||||
Do you support this person? | Yes |
If you support adults in your household, explain why you must support them:
Are you currently employed?
Yes / No How long employed/unemployed?
Highest Grade/Degree completed: ____________________
In the past ten (10) years, what was your longest term of employment?
(employer/job title/how long)
Are you currently still doing that type of work? Yes / No
If no, describe any barriers preventing you from going back to that type of work:
Do you have any physical or mental health conditions that make it difficult for you to work or manage your money?
If yes, describe:
List any other reasons you would like the judge to know about why it is difficult for you to earn enough income to pay your fines/fees off:
EXPENSES
List your expenses. The Court may ask you to provide proof of these expenses, so bring proof with you to your cost hearing.
Expense: | Amount: | Last time late (or Expense: amount behind): | Amount: | Last time late (or amount behind): | |
Rent/Mortgage | |||||
Utilities (Water/Phone/Power) | |||||
Car payment | |||||
Insurance | |||||
Child care/expenses | |||||
Medical Bills Insurance/Prescriptions |
List any additional expenses:
Do you pay child support? Yes / No If so, how much per month? __________
Are you behind on child support? Yes / No If so, how much? __________
Do you have to pay any other expenses on these cases (restitution, DA fees, probation fees, drug test fees)?
If yes, please describe.
When was the last time you had difficulty paying for food?
What did you do?
When was the last time you had difficulty paying for housing?
What did you do?
ASSETS
Do you own the following:
Your Home: Yes / No
Investments (stocks/bonds): Yes / No
Other land/homes: Yes / No
More than one vehicle: Yes / No
(Car, truck, motorcycle, Boat, ATV, etc.)
The land your home is on: Yes / No
Vehicle: Yes / No (With Loan Yes / No)
Bank Accounts: Yes / No Value: ____________________
If you answered “Yes” to any of the answers in the box above, please describe this property:
List any additional expenses:
When was the last time you had to sell or pawn something to pay for an expense?
Describe what happened.
OTHER INFORMATION
Is there a definite date when your financial situation will improve or worsen?
(For example, you will start working on X date, your disability payments will start on X date, or you will lose your housing on X date.)
If yes, please describe.
If someone can verify your financial situation, please attach a letter from that person. For example, a case manager at a shelter, a clergy member who provides you with assistance, etc.
I declare under penalty of perjury under the laws of Oklahoma that the foregoing is true and correct to the best of my knowledge and belief.
Date: ____________________ Respectfully submitted,
Signature
Name
Address
Phone
Additional information:
[ ] Attached ______________________________
[ ] Not Attached Phone
ADDITIONAL INFORMATION
Use this page if you need additional space to respond to any question. Attach additional pages if needed. Please indicate which section you are responding to (e.g. Benefits, Income, Expenses, Assets, Other).
Credits
Adopted effective November 8, 2023.
Court of Criminal Appeals Form 13.17a, 22 O. S. A. Ch. 18, App., OK ST CR A CT Form 13.17a
Current with amendments received through April 15, 2024. Some rules may be more current, see credits for details.
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