Pauper’s Affidavit Respondent/Defendant. )

1 IN THE DISTRICT COURT IN AND FOR THE COUNTY OF TULSASTATE OF OKLAHOMA,)Petitioner/Plaintiff.))and / vs.)Case No. ),)- Pauper s Affidavit - respondent / defendant .)Name: Social Security No. Address: : Are you employed? G Yes G No If yes, who do you work for:Salary or rate per hour. $ How long at this job? If you are not employed, what is your source of income and what is your gross monthly income:Source: Amount: $ you G rent or G own your residence? How much is your rent or mortgage payment $List the names of the persons living with you and their relationship to Resources. List the following items:a. Bank Accounts: $BankBalance $BankBalanceb.

2 Cash on Hand:c. Securities, Stocks, Bonds: $DescriptionBalanced. Are you due a tax refund? G Yes G No If so, how much is the refund? $e. Life Insurance Cash Value: $Name of the CompanyValuef. Does anyone owe you money? G Yes G No If so, who and how much: g. Do you have any pending lawsuits for the recovery of money? G Yes G No If so, list: CourtCase NumberDefendantAmount Sued Forh. If you own any of the following, state the value: Home $ Car/Truck $ Boat $ Jewelry $ Furniture $ Tools $ Appliances $ Car/Truck $ Boat $ :What charge accounts do you have and debts do you owe?

3 CreditorBalanceMonthly Payment CreditorBalanceMonthly Payment CreditorBalanceMonthly Payment CreditorBalanceMonthly PaymentWhat are your average monthly utility bills?Electricity: $Phone: $Water/Trash: $Gas: $ you transferred or sold any property since this case was filed? G Yes G No If yes, describe the buyer, the propertytransferred, the date the property was transferred and the amount you received? you have an attorney in this or any other pending civil or criminal case? If so, what is the attorney s name and how much haveyou paid the attorney? you have any friends and/or relatives who are able and willing to assist you in hiring an attorney and/or paying the costs of thiscase?

4 G Yes G No If the answer is yes, have those persons been asked for help? G Yes G No I swear ( or affirm under penalty of perjury ) that I am without funds or other sources of income topay an attorney and/or to pay the costs associated with this case. I have READ and UNDERSTAND theabove sworn statement and understand that if it is knowingly false, a charge of PERJURY could be filedagainst me. ( Petitioner/Plaintiff ) / ( respondent / defendant )STATE OF )COUNTY OF ) and sworn to before me on [date] .My Commission Expires:Notary PublicORDER RELATING TO COURT COSTSThe Court finds there exists sufficient proof of indigence, and orders that the Affiant shall be allowed to proceed without payment ofcosts, which costs shall be: G Waived in full G Reconsidered at the next hearing G Assessed before the final order isentered.

5 Judge of the District CourtORDER APPOINTING ATTORNEY FOR INDIGENTThe Court finds there exists sufficient proof of the above-named party s indigence, and that an attorney should be appointed torepresent said party. The Court hereby appoints: Next Hearing Date is: .Dated: Judge of the District Court