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Financial Affidavit Pre Decree 75 - Oklahoma
| Financial Affidavit Pre Decree Form. This is a Oklahoma form and can be used in General District Court Statewide . |
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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 Number American LegalNet, Inc. www.USCourtForms.com PRIMARY EMPLOYER NAME: ______________________________________________________________________ PRIMARY EMPLOYER ADDRESS: ___________________________________________________________________ Street, City, State, Zip Code PRIMARY EMPLOYER TELEPHONE: ________________________________________________________________ AVERAGE NUMBER OF HOURS WORKED PER WEEK: ______________________________________________ HOURLY; WEEKLY; MONTHLY; ANNUALLY AND CIRCLE THE BASIS ON WHICH YOUR PAY IS BASED: INDICATE WHAT YOUR PAY IS FOR THE CIRCLED AMOUNT: $_____________________________________. CIRCLE HOW OFTEN YOU ARE PAID: WEEKLY; EVERY 2 WEEKS; TWICE MONTHLY; MONTHLY; HOW LONG HAVE YOU WORKED FOR THIS EMPLOYER:_____________________________________________ SECONDARY EMPLOYER NAME: ________________________________________________________________ SECONDARY EMPLOYER ADDRESS: _____________________________________________________________ Street, City, State, Zip Code SECONDARY EMPLOYER TELEPHONE: ___________________________________________________________ HOURLY; WEEKLY; MONTHLY; ANNUALLY AND CIRCLE THE BASIS ON WHICH YOUR PAY IS BASED: INDICATE WHAT YOUR PAY IS FOR THE CIRCLED AMOUNT: $_______________________________________ CIRCLE HOW OFTEN YOU ARE PAID: WEEKLY; EVERY 2 WEEKS; TWICE 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 Wages Commissions Dividends Bonuses Severance Pay Pensions Rent Interest Income Trust Income Annuities American LegalNet, Inc. www.USCourtForms.com FATHER MOTHER Social Security Benefits Workers' Compensation Benefits Unemployment 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 FATHER MOTHER American LegalNet, Inc. www.USCourtForms.com Medical Insurance Dental Insurance Life Insurance Other Other deductions Other deductions Other deductions Credit Union (specify whether for savings or loan payment) 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: American LegalNet, Inc. www.USCourtForms.com CREDITOR'S NAME PURPOSE 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 known to me owned individually or jointly (indicate who 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 (a) Household furnishings, appliances, and equipment OWED THEREON (b) Automobiles (Year-Make) (c) Securities - stocks bonds (d) Cash and Deposit Accounts (banks, Ravings loans, credit unions - savings and checking) : American LegalNet, Inc. www.USCourtForms.com Life Insurance: Name & Address of Company Policy No. Face Amount Cash Value Accumulated Div. Or Loan Amount 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 Type of Property Date of Acquisition American LegalNet, Inc. www.USCourtForms.com Mtg. Balance Equity Basis of Valuation Taxes Other Liens Total Present Ma
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