Post-Decree Financial Affidavit - Oklahoma District Court (Page 5 of 7) in pdf

Post-Decree Financial Affidavit - Oklahoma District Court Page 5

Regular medical expenses of the children not covered by insurance

*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 Em ployee Only:

$_________________

Premium for Em ployee and Dependants:

$_________________

Premium for Child(ren) Only:

$_________________

Names of Dependent(s) currently covered: ____________________________________________________________

*** Child Care: Projected annual child care costs for the next tw elve (12) months:

MONTHLY PROJECTED CHILD CARE COSTS

JAN $______

FEB $_______ MAR $_______ APR $_______ MAY $_______ JUN $_______

JUL $_______ AUG $______ SEP $_______ OCT $_______ NOV $_______ DEC $________

$________________ divided by 12 = $____________________

Total Cost

Average Monthly Cost

NAMES OF CHILDREN IN CHILD CARE:

__________________________________________________________

NAME OF CHILD CARE PROVIDER:

__________________________________________________________

ADDRESS OF CHILD CARE PROVIDER

__________________________________________________________

Street,

City,

State,

Zip

Post-Decree Financial Affidavit - Oklahoma District Court Page 5