Form 99 - Pauper'S Affidavit
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1
2FORM 99
COURT OF EXISTING CLAIMS
THIS SPACE FOR COURT USE ONLY
1915 NORTH STILES, STE 127
OKLAHOMA CITY, OK 73105-4918
Send original to the
Court of Existing Claims and 1 copy to
All Other Parties of Record
(Please type or print)
Name of Claimant: (Injured Employee)
Mailing Address: (include City, State & Zip)
Social Security Number: (LAST 4 DIGITS ONLY)
PAUPER’S AFFIDAVIT
XXX-XX-___________________
Respondent: (Employer)
WCC FILE NO.
Sec. 1: PERSONS IN HOUSEHOLD (please name the individual(s) and mark
whether they are claimed as a dependent by you.
Spouse:
Dependent?
YES
NO
Children:
Dependent?
YES
NO
___________________________________________________ Dependent?
YES
NO
___________________________________________________ Dependent?
YES
NO
Others
Dependent?
YES
NO
Are you claimed as a dependent by parent or guardian?
Dependent?
YES
NO
If YES, please explain:
___________________________________________________________________________________________________________
Sec. 2: FINANCIAL STATUS/ASSETS
C
Cash on Hand:
A
S
H
Bank Name:
Bank Address:
Account # :
Checking or Savings:
Amount in
B
A
Account:____________________________________________________________________________________________________________________
N
K
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
B
O
Bonds & Securities—Please Describe:
Value:
N
D
___________________________________________________________________________________________________________________________
S
___________________________________________________________________________________________________________________________
O
All Other Possessions of Monetary Value:
Please Describe (including tax refunds, notes, accounts receivable, etc.)
Value
T
H
E
__________________________________________________________________________________________________________________________
R
__________________________________________________________________________________________________________________________
Name of Employer:
Address of Employer:
City
State
Zip
Telephone #
(
)
Earnings:
Weekly
Monthly
Are you currently working?
If Not Currently Employed, Name of Last Employer:
Address of Last Employer:
City
State
Zip
Date of Last Employment:
Supplemental Income Sources (V.A. Soc. Security, Disability, Child Support etc.):
Amount:
Is Amount Weekly or Monthly:
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Home & Other Real Estate (please describe):
Value
Balance Owed
Vehicle(s) (please describe):
Value
Balance Owed
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Personal Property (furniture, appliances, etc.):
Value
Balance Owed
Litigation you or your spouse have pending for recovery of money:
Case #
County
______________________________________________________________
______________________________________________________________
______________________________________________________________
Rev. 06/24/2015
Please fill out the remainder of the information on the reverse side of this Form
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