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IN THE DISTRICT COURT OF
__________________________________________________ Plaintiff,

COUNTY STATE OF OKLAHOMA

Case No. v. __________________________________________________ Defendant,

FINANCIAL AFFIDAVIT (Post-Decree) 43 O.S. § 118 IN COMPLETING THIS FORM, YOU ARE NOT REQUIRED TO PROVIDE ANY INFORMATION FROM A DATE EARLIER THAN THE DATE OF THE LAST DECREE/ORDER ENTERED IN THIS CASE THAT MODIFIED CHILD SUPPORT.
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.
Names of child(ren) who is/are the subject to child support payment:

________________________________________________________________________________

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 WEEKS; 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 FATHER MOTHER

Rent Interest Income Trust Income Annuities Social Security Benefits W orkers' Compensation Benefits Unemploym ent Insurance Benefits Disability Insurance Benefits Gifts Prizes All other sources (Specify)

TOTAL GROSS MONTHLY INCOME

$

$

YOU MUST DISCLOSE ALL GROSS INCOME (12 O.S. 1170).

IF REQUIRED TO DO SO BY 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 THE 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

FATHER

MOTHER

Income Assignment Withholding Union or other dues Retirement or pension fund Savings plan Medical Insurance Dental Insurance Life Insurance Other 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

MOTHER

Regular medical expenses of the children not covered by insurance

*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 Em ployee Only: Premium for Em ployee and Dependants: Premium for Child(ren) Only:

$_________________ $_________________ $_________________ $_________________

Names of Dependent(s) currently covered: ____________________________________________________________

*** Child Care: Projected annual child care costs for the next tw elve (12) months: MONTHLY PROJECTED CHILD CARE 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

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 74
Revised 9/05