STATE OF OKLAHOMA

In the Supreme Court of Oklahoma:

I, __________, depose and say that I am the __________, in the above-entitled case. I further state that it is my intent to remit the cost deposit for this cause of action via credit card, debit card or other form of electronic payment, and that I am authorized to utilize the provided method of payment.

I understand that it is my responsibility to remit the cost deposit and to ensure that the Clerk of the Supreme Court has received and successfully processed the cost deposit not later than two business days after the date of filing this Form 4A. I accept full responsibility to provide the Clerk of the Supreme Court with any and all information needed for the processing of my remittance. I further understand that if I fail to timely and successfully remit the cost deposit for this cause of action in the form and manner prescribed by the Rules of the Supreme Court, my cause of action may be dismissed for failure to remit the cost deposit as required by Oklahoma law.

I further understand that I should not provide, on this Form 4A, the actual credit or debit card numbers or any other sensitive information for the processing of this cost deposit. I understand that the Clerk of the Supreme Court will not retain any of this information for any use other than the processing of this cost deposit after I have communicated with the Clerk and provided it.

I state under penalty of perjury under the laws of Oklahoma that the foregoing is true and correct.

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