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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: ADDRESS: CITY, STATE, ZIP SOC SEC NO: OCCUPATION: PRIMARY EMPLOYER: BIRTHDATE: MOTHER: ADDRESS: CITY, STATE, ZIP SOC SEC NO: OCCUPATION: PRIMARY EMPLOYER: 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 Num ber

PRIMARY EMPLOYER NAME: ______________________________________________________________________

PRIMARY EMPLOYER ADDRESS: ___________________________________________________________________ Street, City, State, Zip Code PRIMARY EMPLOYER TELEPHONE: ________________________________________________________________ AVERAGE NUMBER OF HOURS WORKED PER WEEK: ______________________________________________ CIRCLE THE BASIS ON WHICH YOUR PAY IS BASED: HOURLY; WEEKLY; MONTHLY; ANNUALLY AND INDICATE WHAT YOUR PAY IS FOR THE CIRCLED AMOUNT: $_____________________________________. CIRCLE HOW OFTEN YOU ARE PAID: W EEKLY; EVERY 2 WEEKS; TW ICE MONTHLY; MONTHLY;

HOW LONG HAVE YOU WORKED FOR THIS EMPLOYER:_____________________________________________ SECONDARY EMPLOYER NAME: ________________________________________________________________ SECONDARY EMPLOYER ADDRESS: _____________________________________________________________ Street, City, State, Zip Code SECONDARY EMPLOYER TELEPHONE: ___________________________________________________________

CIRCLE THE BASIS ON WHICH YOUR PAY IS BASED: HOURLY; WEEKLY; MONTHLY; ANNUALLY AND INDICATE WHAT YOUR PAY IS FOR THE CIRCLED AMOUNT: $_______________________________________ CIRCLE HOW OFTEN YOU ARE PAID: W EEKLY; EVERY 2 W EEKS; TW ICE 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 Salary W ages Commissions Dividends Bonuses Severance Pay Pensions Rent Interest Income Trust Income Annuities Social Security Benefits W orkers' Compensation Benefits FATHER MOTHER

Unemploym ent 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: State income taxes Federal income taxes Number of exemptions taken FICA Income Assignment Withholding Union or other dues Retirement or pension fund Savings plan Medical Insurance Dental Insurance Life Insurance Other FATHER MOTHER

Other deductions Other deductions Other deductions Credit Union (specify w hether for savings or loan paym ent) TOTAL PAY PERIOD DEDUCTIONS FROM GROSS INCOME NET PAY PERIOD INCOME (TAKE HOME PAY) $ $ $ $

OTHER:
FATHER 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 MOTHER

*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:

PURPOSE CREDITOR'S NAME FOR DEBT

DATE PAYABLE BALANCE

MONTHLY PAYMENT

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 know n to me ow ned individually or jointly (indicate w ho 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

OW ED 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) :

Life Insurance:

Name & Address of Com pany

Policy No.

Face Am ount

Cash Value Accumulated Div. Or Loan Am ount

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 Original Cost Mtg. Balance Equity Basis of Valuation

Type of Property Date of Acquisition Taxes Other Liens 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): _________________________________________________________________________________________________ _________________________________________________________________________________________________ ______________________________________________________________________________________________Oth er Assets (Specify):_________________________________________________________________________________________

_________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ ____

*** Child Care: Projected annual child care costs for the next tw elve (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

VERIFICATION

STATE OF OKLAHOMA ) SS.

)

COUNTY OF ______________

)

_______________________________________ 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