                           --jLse Number.


^VVj:iticrer,
                                                         n rhe

                                                                      1*,               3&r<lcSl>P ^_csc^s«-
                                                                      -* ^'Strict Court  ^    &06&H&
                                                                      ~ Cc""ty Court at Law



                                               Affidavit of Indigency                %&                 '% %
      -'se^formioaskmecoorinono                                                         *«*
      f^'vou for court fees. This farm
                                                                                  ""ou can b. PfoaaeuS^ftfe.,,
                                                                                  on this farm.        ""Pu •<•
                                                                                                               ..
      'am-wC0SlS0r3        pauper'57
      -am 'ou can only us. m farm,f-                                               ™9 court may ormayno|
      M/oU,eiDuol,cl)enef„a6
     ;oUa.ooor0ri2)youcantpav'              •nformahonprov,^,,                    r"e court may order you to a„!Z'
     :ounlees.
                                                                                  luesdon, aoou, your«££« £*'
    'r-,™»"lm'a"<"'you9,veo"'n's
                                                                                 ^v.,0 present ev,danc9To,^
                                                                                 i"d9« olyour.neome ana exl*
                                                                                 'oorov„ha,younav9an^^»nses
     DJh.p.rlwnwhos|
    iT» ti.
                                             °'r~«-
                                            correct.         — "uuaana
                                                                                 pay court
                                                                                  "'
                                                                                 Pay       fees.       °a0,"1
                                                                                        »»•« you nave no abnir.
                                                                                     court tees.       ua°wty to
    undafowh:                  ""* ",,d,v', appeared, in pwaon b#fcM „ ,

    r * 5 M ^ S S T ^ 7 ^VPnon.nun1t!afisl^^^
   ~3.m.na.r.anaa™u-^^
   ;^:im'mw-'^-'---..»^.Z                                  •OTd8,08n8"ar'^-^.nc,owc°-

   _- eMwrny^aMM.               - chili r .""Ca"*" 0A°S               NLoJln^ ^ ^"^


 — Wages: I wont as a
 - Child/5Dousal suoport3t t-
                           'Z .^
                              My SD~~~~':u"0<>""»
                                       - ''3uf^«*            "" *'
                                                                ' 'or                       ^___


°) Th, amoijn,,           a""'*"» *• taken out ia:
=) Th.amoumotaV^^r'"°Ud,ie'""«*<*                                       "V T3JT* *.•„,


>» Tha .mount, race v, , cn         0e°°"'" "* nouMn™ *'
                                                                                         ?". M
                                 "-'«?
                                                            ~ctf,rf •<"«•« o/rwm.,00^.           = S
                                                                                                       j&i.
                                                                                                        -\%m 1 of 2
               -' -douimy d9p<,naBn(S: •rhe oeccie v
                   • .a
                                                               >"o cecena en me financially are listed below:




      '5 My property includes:                              value'
     Cash                                                                 3"My monthly expenses are:
                                                        s                                                                     Amount
     3ank accounts, other financial assets ,i,„,                          Sent/house payments/maintenance
                                                                           Pood and household supplies
                                                                           Utilities and telephone
                                              .         3
                                                                           Clothing and laundry
                                                        5
    Vehicles (cars, boats)«.,» ma*9 ana year;                              Medical and dental expenses
                                                    . 5_
                                                                          insurance (life, health, auto, etc)
                                                                          School and child care
                                          .             S
                                                                          Vehicle payments
                                                                          Gas, bus fare, auto repair
    *eal estate (house or land) too nottta 1ZZ         Ch"d' SP°UMl S4Jpport
                                        ^"••"•^-•^•••J Wages withheld by cou                  court order
                   —-* """" ~                       • *                   Debt payments
   Other property (like jewelry, stocks, etc.) tOtscribmf            -    Other expense tOmtwumk




                   Total value ofproperty ^=$ C<f \
       • •< *•- •..,..,, ,,,..,,„ .„.„,.w J.,,.^,,*^ \ ,(                             Tatal monthly Expenses       l^C^
   a> *My debts include: l-,, -.., ,.„.„.„.,, ... ^ ^
                                                                                                     cxv




                                                                                                           are true and correct.1
 J Your Signature.            '   *:j




  > uJ33e~&0a~#-t'Jst                                                                                             '. -•:•   ;f ;''C»   '~rrn




 State of Texas
 County of
 — '-~f •»« - n/r»a -.                  ^»^^-^—^—   _
          -      •-'-<-••<   ...*e .-ra,--aw ,.ra/-
 Sworn :o and sufiscrceo before me today.
                                                                                .-y




•"-.u*™.*, .^eew^^wcy NovrrcuOK                                                                                                        '*;• 2. ot 2
• V




                                                     Unsworn Declaration
                                 (Texas Civil Practice and Remedies Code, Section 132.001)
          My name is: &J CLC/Jn^                     /2g ^ r                                   Aj ^/^^//fO^S
                                                                     M,ddle                                      j^—
         my date of birth is: s/            I ^5~ I ZfcL                 and
                                                          Year



         myaddressis:S**>rs»w,
            f
                               ,y.(^
                               «V
                                      -rv
                                     State
                                                                                                                 wro
                                                                                                                  —~^—  Zip Code
         and KIA-CJC^
                            Country


         (Ifyou am incarcerated, you must also include the following information.)
         My inmate identifying number, if any, is:              /'Cj S~$' Y^^L.
         Iam presently incarcerated in:
                                                                              Corrections Unit Name
        in:
                 City
                                                        Counil                                  State                  Zip Code



        Ideclare under penalty of perjury that all information in the attached document titled.
                                  Name of Document               7                    •        •        •' ,S trUe and COITOCt

        Signed in J/H-^                     County
                                                                          County,          -t&c/h
                                                                                                        State
        on this date: _/0__ I<£<£. / /JT_
                        Month         Day        Year



                                                                 Your Signature                             "      ~




      ©TexasLawHelp.org - Unsworn Declaration, August 2012
                                                                                                                   Page 1 of 1
