inmate-affidavit-inability-to-pay.doc - IN THE DISTRICT COURT OF COUNTY STATE OF OKLAHOMA Plaintiff vs Defendant Case No PRISONERS AFFIDAVIT OF

inmate-affidavit-inability-to-pay.doc - IN THE DISTRICT...

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IN THE DISTRICT COURT OF __________ COUNTY STATE OF OKLAHOMA _________________________, Plaintiff, vs. Case No. ______________________________ _________________________, Defendant. 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.)
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  • Spring '08
  • net weekly wages, Gross weekly wages

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