Yes( ) No( )
Yes( ) No( )
Yes( ) No( )
Yes( ) No( )
Are you claimed as a dependent by parent or guardian?
If so, explain: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________
II. FINANCIAL STATUS--ASSETS (Defendant or person(s) responsible for defendant's support):
1. Cash on Hand: $ _________________________
2. Bank Accounts:
Bank Name/Address Last four digits of Account # Checking/Savings $ Amount
______________________________________________________________________________________________________________________________________________________________________________________________________________________________
3. Bonds & Securities
Description Value
______________________________________________________________________________________________________________________________________________________________________________________________________________________________
4. All Other Possessions of Value: (including tax refunds, notes, accts. receivable, etc.)
Description Value
______________________________________________________________________________________________________________________________________________________________________________________________________________________________
1. Current Employment: __________________________________________________________________________
____________________________________________________________________________________________________________________________________________________
2. Earnings: __________________________________________________________________________
____________________________________________________________________________________________________________________________________________________
3. If not currently employed, last employment:
Place & Date: __________________________________________________________________________
____________________________________________________________________________________________________________________________________________________
4. Supplemental Income: (V.A., Soc. Security, Disability, Child Support, etc.) ______________________________________________________________________________________________________________________________________________________________________________________________________________________________
Home and Other Real Estate:
Real Property Value Balance Owed
______________________________________________________________________________________________________________________________________________________________________________________________________________________________
Vehicle(s):
Description Value Balance Owed
____________________________________________________________________________________________________________________________________________________
__________________________________________________________________________
Personal Property: (furniture, appliances, tools, equipment, etc.)
Items Market Value Balance Owed
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Litigation you or your spouse have pending for recovery of money:
Case No. County
__________________________________________________________________________
Charge or Open Accounts:
Description Balance
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Housepayment or Rent:
Mortgagee/Landlord Monthly Payment
__________________________________________________________________________
If own, balance:_____________________________________________________________
Child Support Obligations
Monthly Payment:___________________________________________________________
Other Debts:
Creditor Balance
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Have you transferred or sold any assets since charges were filed in this case? Yes( ) No( )
If so, describe the buyer and the amount received:
__________________________________________________________________________
___________________________________________________________________________
Have you retained counsel in this case or in any other pending criminal case? Yes( ) No( )
If so, state the case number, court, attorney and amount paid to attorney for services:
___________________________________________________________________________
___________________________________________________________________________
If you have posted bond, who provided the funds for the bond?
___________________________________________________________________________
Do you have any friends or relatives who are able and willing to assist you in hiring counsel and paying for transcripts? Yes( ) No( )
If so, have those persons been asked to help? Yes( ) No( )
If a friend or relative has given previous financial assistance in this case, including the posting of bond, but is no longer able or willing to do so, an affidavit to that effect from that person shall be attached, stating why such help is no longer available.
I further swear and affirm that I am without funds or other sources of income to pay an attorney or to pay for transcripts and costs associated with this case. I understand I am under a continuing obligation to keep this Court informed of any changes in my financial status and this Court may conduct another hearing to determine my indigent status at any time.
Subscribed and sworn to before me this __________ day of ___________________ 20_______.
State of Oklahoma
County of ______________________ OR
My Commission Expires__________________
By: _________________________
Deputy