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                                                                                                                      FILED IN COURT OF APPEALS
                                                                                                                        12th Court of Appeals DfeMct /
 NOTICE: THIS FORM CONTAINS SENSITIVE DATA.
                                   Cause Number:
                                                     The Clerk's office will fill in the Cause Numberwhen you ft J Mis ft irm.)
                                                                                                                                  APR-9:2015.
                                                                                    n the (checkone)
                                                                                                                                            -I
Petitioner/                                                                                                                       TYLER TEXAS
Plaintiff                                                     y^>r\             ^5JrYN ST District cjou£ATHY S. LUSfocjpLEFfcte                  i*i.
                                                                               (Court Number)     Q County Court at Law
                                                                                                  •    Justice of the Peace

Respondent/
Defendant
                           £2s<d A. A>                   *o o
                                                                               (County)
                                                                                          1*^30><r\S                          County, Texas


                                                               Affidavit of Indigency
                                                               (Request to Not Pay Court Fees)
     Use this form to ask the court not to                  You must either 1) sign this form in                 You can be prosecuted if you lie on
     charge you for court fees. This form is               front of a notary public or 2) sign this              this form.
     also called an "Affidavit of Inability to             form and sign and attach a completed The court may or may not approve tnis
     Pay Court Costs" or a "Pauper's Oath."                "Unsworn Declaration" form. By          request to not pay court fees. The court
     You can only use this form if: (1) you                signing in front of a notary, you swear may order you to answer questions
     get public benefits because you are                   under oath that the information
                                                                                                   about your finances at a hearing. At
     poor or (2) you can't pay court fees.                 provided is true and correct. By        that hearing you will have to present
     The information you give on this form                 signing and attaching an "Unsworn       evidence to the judge of your income
     must be current, complete, true and                   Declaration" form, you declare under and expenses to prove that you have no
     correct.                                              penalty of perjury that the information ability to pay court fees.
                                                            provided is true and correct.
     ® The person who signed this affidavit appeared, in person, before me, the undersigned notary, and stated
     under oath:

     "My name is £~Js<^ / A. QxjbmQ                                                          , My phone number is (683. )30l-^t?qD-
     "My mailing address is *?3S ^UJ^k Y>,                                                  Are>.C*xjirse. , ^TTM. ^CO^i
     "My email address is         g_dcWors <^Ci'< (€) c^CTscri i'.. C^sv^
                                                                 -? to make this affidavit. Iam unable to pay court
     "I am above the age of eighteen (18) years, and I am fully competent
     costs. The nature and amount of my income, resources, debts, and expenses are described in this form.
     Check ALL boxes that apply and fill in the blanks describing the amounts andsources ofyourincome.
     ®   "I receive these public benefits/government entitlements thatare based on indigency:
     •   SSI       DWIC        • Food Stamps/SNAP         • TANF       • Medicaid       • CHIP      • AABD
     •   Needs-based VA Pension          • County Assistance, County Health Care, orGeneral Assistance (GA)
     •   LIS in Medicare ("Extra Help")      • Community Care via DADS        • Low-Income Energy Assistance
     D   Emergency Assistance        • Child Care Assistance under Child Care and Development Block Grant
     •   Public Housing      Q Other: (Describe)
                            Ifyou receive any of the above public benefits, attach proof and label it "Exhibit: Proof of Public Benefits"

      ® "My income sources are stated below. (Check all that apply)
     D Unemployed since: (date)                                                                         -or-
     -K'Wages: Iwork as a       Z^Wr?,I f l A ' . ^       /ec^-A -
                                                                   Your job title
                                                                                                        f°r feu/fc^ YourPloAu-k
                                                                                                                         employer
                                                                                                                                  Re^l-Lf
     • Child/spousal support • My spouse's income or income from another member of my household (if available)
     • Tips, bonuses • Military Housing Q Worker's Comp • Disability • Unemployment • Social Security
     • Retirement/Pension [J Dividends, interest, royalties D 2nd job orother income:
                                                                                                                                    (describe)
     © "My income amounts are stated below
     (a) My monthly net income after taxes are taken out is:                                              Total income after taxes ->
                                                                                                                                                              o <3

     (b) The amount I receive each month in public benefits is:                                                Total amount received -*      $          -&
     (c) The amount of income from other people in my household is:*                                           Total amount received ->      $          -0-
     (d) The amount I receive each month from other sources is:                                                Total amount received -#
                                                                                                                                                        &
     (e) My TOTAL monthly income is                                            Add allsourcesofincome above
         *List this income only if other members contribute to your household income.
                                                                                                                                            = IjiBaE0           o


                                                                                                                                                         Page 1 of 2
©TexasLawHelp.org - Affidavit of Indigency, February 2014
© About my dependents: "The people who depend on me financially are listed below:
          Name                                                                                             Age                    Relationship to Me
    1
    2




    5

    6


  © "My property includes:                                                        ©"My monthly expenses are:                                        Amount
  Cash                                                                             Rent/house payments/maintenance                          $     <3os-go
  Bank accounts, other financial assets (List)                                     Food and household supplies                              $ ?ko: °o
                                                    $       -&-                    Utilities and telephone                                  $     2ooc0
                                                    $      lS^                     Clothing and laundry                                     $           •&
                                                                                   Medical and dental expenses                                                  oQ
                                                          jSl                                                                                     J4&-
  Vehicles (cars, boats) (List make andyear)                                       Insurance (life, health, auto, etc)                                  -&-
                                                                                   School and child care                                                -e-
                                        i           $        -£5-                  Vehicle payments                                                     -e-
                                                            **S-                   Gas, bus fare, auto repair                                            -er
                                                    $      &-                      Child / spousal support
   Real estate (house or land) (Do notlist thehouseyoulive in.)                   Wages withheld by court order                             $            u-
                                                    $       jg£r                   Debt payments                                                         -e-
                                                                                   Other expenses (Describe)
  Other property (like jewelry, stocks, etc.) (Describe)                                                                                                -<&
                                                    $       ^^                                                                                          •©-
                                                                                                                                                        •G-

                  Total value ofproperty -* |= $fx3Q-°°                                        Total monthly Expenses
                                                                                                                                             =$/)9£f?Q-                CO

    'The value is the amount the item would sell for less the amount you still owe on it (ifanything).

  © "My debts include: List debt and amount owed.                            s*\—



  Tolist any other facts you want the court to know, such as unusual medical expenses, family emergencies, etc., attach another
  page to this form and label it "Exhibit: Additional Supporting Facts." Check here ifyou attach anotherpage.O
  ® "I am unable to pay court costs. Iverify that the statements made in this affidavit are true and correct."
  ® Your Signature. You must either: 1) sign this form in front ofa notary public or
        2) sign this/prm and sigffhpd attach a completed "Unsworn Declaration'' form.


                                                                       Notary fills out this section if you
    State of Texas
                                                                       are signing in front of a notary.
    County of         "fcyyJUT"                                                                                                  Notary stamp here
    Print the name of county where this Affidavit is notarized.

    Sworn to and subscribed before me today, Any}) 7                              2f>i % , by &o£&\ f\wi&S 7)\XOH.
                 \Lf fih7        /] y         /^»                 '       Plato
                                                                          Date                   Drirtt name
                                                                                                 Print  rt**ma of
                                                                                                               r\f person
                                                                                                                   r\esrt*s\n ttihn
                                                                                                                              who isle* signing
                                                                                                                                        n!nn;'nA this
                                                                                                                                                 fkiV. Affidavit.
                                                                                                 NOT the notary's name.
         Notary's Signature                     r**-****!^™**********^**************^^^^


                                                                        SHILU SHRESTHA
                                                                         NOTARY PUBLIC
                                                                                                                                                                    Page 2 of 2
© TexasLawHelp.org - Affidavit of Indigency,                            STATE OF TEXAS
                                                                      MYCOMM.EXR 11/08/17
