Form 13.17a Affidavit Regarding Ability to Pay IN THE DISTRICT COURT OF ___________ COUNTY STATE OF OKLAHOMA STATE OF OKLAHOMA,
Plaintiff, v. ___________________________,
Defendant. )
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) Case Nos.: __________________ __________________ __________________ __________________ __________________ __________________ AFFIDAVIT REGARDING ABILITY TO PAY [This affidavit and any supporting documents shall not be visible on a court-controlled website. 22 O.S. § 983(I).
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
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Income Amount:
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_______________ Income source: (employment, gift, etc.)
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How often? (week/month)
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Yes
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_______________ 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 amount behind): Expense: Amount: Last time late (or amount behind):
Rent/Mortgage
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Car payment
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Insurance
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Child care/expenses
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_______________ 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, 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). ______________________________________________________________________________ ______________________________________________________________________________

Adopted by order of the Court of Criminal Appeals, 2023 OK CR 17, eff. November 8, 2023.