OCA STANDARDIZED FORM AND INSTRUCTIONS
11/23/21
10
INSTRUCTIONS FOR COMPLETING EXHIBIT A
1. Enter the cause number of the case. If you don’t know it ask your community
supervision officer or the clerk of the court.
2. Check this box if you lost your job or other source of employment income
after the court last determined your ability to pay. Include the date that you
lost your job or other employment.
3. Check this box if you lost a source of income after the court last determined
your ability to pay. Examples of such income include but are not limited to
retirement or pension income, social security income, income from child or
spousal support, income from tips or bonuses, disability or worker’s
compensation income, income from dividends, interest or royalties, income
from unemployment benefits, your spousal’s income, and income from another
member of your household. Include the amount of the loss, the date of the
loss, and a brief explanation of what income was lost and under what
circumstances.
4. Check this box if you lost a public benefit or government entitlement after the
court last determined your ability to pay. Examples of such benefit or
entitlement include but are not limited to food stamps/SNAP, TANF, Medicaid,
Public or Section 8 housing, Supplemental Security Income (SSI), Need based
VA pension, WIC, and Emergency or General Assistance.
5. Check this box if you lost your home, apartment, room, or other place of
residence after the court last determined your ability to pay. Include the date
that you lost your residence or other place to live.
6. Check this box if you lost your car, ride, or other mode of transportation after
the court last considered your ability to pay. Include the date that
transportation was no longer available. You can include the loss of public
assistance for transportation (e.g., bus pass or transportation subsidy).
7. Check this box if you no longer have real estate
(e.g., home, rental property)
or some personal property (
e.g., cash, bank accounts, vehicles, jewelry, stocks,
boats
) that you had when the court last considered your ability to pay. Include
the amount of the loss.
8. Check this box if another court entered a judgment and order withholding all
or part of your wages or employment income after the court last considered