On June 06, 2012 a
Party Statement
was filed
in the District Court of Pushmataha County.
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iN THE DISTRICT COURT
i Pushmataha County, Okla
FILED
IN THE DISTRICT COURT OF PUSHMATAHA County —-2UN 06 2012
STATE OF OKLAHOMA TINA FREEMAN, Court Clerk
RACHEL DAWN LARGENT, ) Deputy
Petitioner )
Vs ) No. FD-2012-2l
. )
WAYLAN DAVE CLARK, )
Respondent )
PAUPER'S AFFIDAVIT
Name: RACHEL DAWN LARGENT
Address; 211 NW “C” STREET, ANTLERS, OKLAHOMA 74523
1. Are youemployed? Yes Sor so, who do you work for?
Salary or rate per hour. How long at this job?
Income from other sources(SS, VA, unemployment) and amount:
2. Do you CEntyor own your residence? How much is your rent or mortgage payment
\so. ?
How many people live in your home with you? _~J
List relationships: reat @tzs reat
beyselP "Sond, abel wy Dougie
3. Financial Resources. List the following items:
1 eC Bank Accounts: $
(Bank) (Balance)
b. Cash on Hand: $0 .°°
Mme. Securities, Stocks, Bonds: $
(Description) (Value)
d. Are you due a tax refund? Yes & Tf so, how much?
e. Life Insurance Cash Value:
f. Does anyone owe you money? Yes Ge If so, who and how much?We g. Do you have any pending lawsuits for the tecovery of money? If so, list:
h. If you own any of the following, state the value:
Home $ Car/Truck $2 doo Boat $
Jewelry $ Furniture $ Tools $
Appliances $ Equipment $.
4. Expenses:
Yow What charge accounts do you have and debts do you owe?
(Creditor) (Balance) (Mo. Payment)
What are your average monthly utility bills?
Electricity Phone
Water/Trash Gas
5. Have you transferred or sold any property since this case was filed? If so, describe the buyer,
the property transferred, and the amount you received? NWO
6. Do you have an attomey in this or any other pending civil or criminal case? If so, what is the
attorney's name and how much have you paid the attorney? wo
7. Do 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 this case? Yes Nope so, have those persons been
asked forhelp? Yes No.I swear (or affirm under penalty of perjury) that | am without funds or other sources of
income to pay an attorney and/or to
pay the costs associated with this case. I have READ and
UNDERSTAND the above sworn statement and understand that if it is knowingly false, a charge
of PERJURY could be filed against me.
Coobi ft
Petitioner
Provil 2019.
oma i
3103/14 |
My Commission Number: O26 / ADA
ORDER RELATING TO COURT COSTS & FEES
It is 0)
and shall be:
waived in full.
Dated: 6- 5- Pd!
ERED that the costs & fees in this case shall be $C at this time,
reconsidered at next hearing; 1 assessed before the final order is entered; 0
—~fudge of the District Court
Document Filed Date
June 06, 2012
Case Filing Date
June 06, 2012
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iN THE DISTRICT COURT i Pushmataha County, Okla FILED IN THE DISTRICT COURT OF PUSHMATAHA County —-2UN 06 2012 STATE OF OKLAHOMA TINA FREEMAN, Court Clerk RACHEL DAWN LARGENT, ) Deputy Petitioner ) Vs ) No. FD-2012-2l . ) WAYLAN DAVE CLARK, ) Respondent ) PAUPER'S AFFIDAVIT Name: RACHEL DAWN LARGENT Address; 211 NW “C” STREET, ANTLERS, OKLAHOMA 74523 1. Are youemployed? Yes Sor so, who do you work for? Salary or rate per hour. How long at this job? Income from other sources(SS, VA, unemployment) and amount: 2. Do you CEntyor own your residence? How much is your rent or mortgage payment \so. ? How many people live in your home with you? _~J List relationships: reat @tzs reat beyselP "Sond, abel wy Dougie 3. Financial Resources. List the following items: 1 eC Bank Accounts: $ (Bank) (Balance) b. Cash on Hand: $0 .°° Mme. Securities, Stocks, Bonds: $ (Description) (Value) d. Are you due a tax refund? Yes & Tf so, how much? e. Life Insurance Cash Value: f. Does anyone owe you money? Yes Ge If so, who and how much?We g. Do you have any pending lawsuits for the tecovery of money? If so, list: h. If you own any of the following, state the value: Home $ Car/Truck $2 doo Boat $ Jewelry $ Furniture $ Tools $ Appliances $ Equipment $. 4. Expenses: Yow What charge accounts do you have and debts do you owe? (Creditor) (Balance) (Mo. Payment) What are your average monthly utility bills? Electricity Phone Water/Trash Gas 5. Have you transferred or sold any property since this case was filed? If so, describe the buyer, the property transferred, and the amount you received? NWO 6. Do you have an attomey in this or any other pending civil or criminal case? If so, what is the attorney's name and how much have you paid the attorney? wo 7. Do 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 this case? Yes Nope so, have those persons been asked forhelp? Yes No.I swear (or affirm under penalty of perjury) that | am without funds or other sources of income to pay an attorney and/or to pay the costs associated with this case. I have READ and UNDERSTAND the above sworn statement and understand that if it is knowingly false, a charge of PERJURY could be filed against me. Coobi ft Petitioner Provil 2019. oma i 3103/14 | My Commission Number: O26 / ADA ORDER RELATING TO COURT COSTS & FEES It is 0) and shall be: waived in full. Dated: 6- 5- Pd! ERED that the costs & fees in this case shall be $C at this time, reconsidered at next hearing; 1 assessed before the final order is entered; 0 —~fudge of the District Court