                                    COURT OF APPEALS FOR THE
                               FIRST DISTRICT OF TEXAS AT HOUSTON

                                                  ORDER

Appellate case name:         Doreatha Walker v. Hartford Underwriters Insurance Co

Appellate case number:       01-16-00828-CV

Trial court case number:     2015-31910

Trial court:                 127th District Court of Harris County

         The record was due on November 14, 2016. On November 17, 2016, the trial court clerk advised
that no financial arrangements had been made for the filing of the clerk’s record. After sending notice to
appellant advising of the possibility of dismissal for not making arrangements for the filing of the clerk’s
record, appellant filed a response in the form of a motion to appeal as indigent. In this motion, appellant
claimed she had filed an affidavit of indigence in October 2016 that was not timely contested.
         We issued an order for the trial court clerk to file a supplemental clerk’s record containing all
indigence filings and contests and orders. A supplemental clerk’s record was filed and it contained an
affidavit of indigence filed on October 15, 2016, the same date appellant filed her notice of appeal.
         Fees charged for the appellate record are governed by Rule 145. See TEX. R. APP. P. 20.1(a)
(amended; effective September 1, 2016). Rule 145 requires a declarant to use the form Statement of
Inability to Afford Payment of Court Costs, which has been approved by the Supreme Court. See TEX. R.
CIV. P. 145(a)–(b) (amended; effective September 1, 2016). The affidavit of indigence filed by appellant
on October 15, 2016 does not comply with Rule 145(b).
         Accordingly, if appellant wishes to proceed without payment of costs or for the fees for
preparation of the appellate record, she must comply with Rule 145(b). See TEX. R. CIV. P. 145(b). The
form Statement of Inability is attached to this order. If appellant files a Statement of Inability in
compliance with Rule 145 in the trial court, she must request the preparation and filing of a supplemental
clerk’s record within 14 days of the date of this order, containing this Statement of Inability.
        It is so ORDERED.

Judge’s signature: /s/ Michael Massengale
                    Acting individually  Acting for the Court


Date: March 21, 2017
  NOTICE: THIS DOCUMENT CONTAINS SENSITIVE DATA
                          Cause Number:
                                                  (The Clerk’s office will fill in the Cause Number when you file this form)
Plaintiff:                                                                 In the       (check one):
         (Print first and last name of the person filing the lawsuit.)                       District Court
                                                                           Court             County Court / County Court at Law
                                And                                        Number            Justice Court
Defendant:                                                                                              Texas
              (Print first and last name of the person being sued.)       County


                              Statement of Inability to Afford Payment of
                                   Court Costs or an Appeal Bond
  1. Your Information
  My full legal name is:                                                                         My date of birth is:          /     /
                                First                   Middle             Last                                            Month/Day/Year

  My address is: (Home)
                      (Mailing) ___________________________________________________________________________________

  My phone number:                                   My email:

  About my dependents: “The people who depend on me financially are listed below.
       Name                                                                                  Age                Relationship to Me
   1
   2
   3
   4
   5
   6

  2. Are you represented by Legal Aid?
     I am being represented in this case for free by an attorney who works for a legal aid provider or who
       received my case through a legal aid provider. I have attached the certificate the legal aid provider
       gave me as ‘Exhibit: Legal Aid Certificate.
  -or-
        I asked a legal-aid provider to represent me, and the provider determined that I am financially eligible
         for representation, but the provider could not take my case. I have attached documentation from
         legal aid stating this.
  or-
        I am not represented by legal aid. I did not apply for representation by legal aid.

  3. Do you receive public benefits?
        I do not receive needs-based public benefits. - or -
        I receive these public benefits/government entitlements that are based on indigency:
        (Check ALL boxes that apply and attach proof to this form, such as a copy of an eligibility form or check.)
        Food stamps/SNAP              TANF       Medicaid        CHIP       SSI     WIC       AABD
        Public Housing or Section 8 Housing      Low-Income Energy Assistance       Emergency Assistance
        Telephone Lifeline            Community Care via DADS               LIS in Medicare (“Extra Help”)
        Needs-based VA Pension        Child Care Assistance under Child Care and Development Block Grant
        County Assistance, County Health Care, or General Assistance (GA)
        Other:



  © Form Approved by the Supreme Court of Texas by order in Misc. Docket No. 16-9122
  Statement of Inability to Afford Payment of Court Costs                                                                      Page 1 of 2
4. What is your monthly income and income sources?
“I get this monthly income:
$            in monthly wages. I work as a                                                      for                                       .
                                                       Your job title                                 Your employer
$              in monthly unemployment. I have been unemployed since (date)                                                               .
$              in public benefits per month.
$              from other people in my household each month: (List only if other members contribute to your
               household income.)
$              from     Retirement/Pension      Tips, bonuses     Disability         Worker’s Comp
                        Social Security         Military Housing  Dividends, interest, royalties
                        Child/spousal support
                        My spouse’s income or income from another member of my household (If available)
$               from other jobs/sources of income. (Describe)
$               is my total monthly income.

5. What is the value of your property?                                  6. What are your monthly expenses?
“My property includes:                Value*                            “My monthly expenses are:                              Amount
Cash                                $                                   Rent/house payments/maintenance                    $
Bank accounts, other financial assets                                   Food and household supplies                        $
                                               $                        Utilities and telephone                            $
                                               $                        Clothing and laundry                               $
                                               $                        Medical and dental expenses                        $
Vehicles (cars, boats) (make and year)                                  Insurance (life, health, auto, etc.)               $
                                               $                        School and child care                              $
                                               $                        Transportation, auto repair, gas                   $
                                               $                        Child / spousal support                            $
Other property (like jewelry, stocks, land,                             Wages withheld by court order
 another house, etc.)                                                                                                      $
                                               $                        Debt payments paid to: (List)                      $
                                               $                                                                           $
                                               $                                                                           $
         Total value of property  $                                                  Total Monthly Expenses  $
*The value is the amount the item would sell for less the amount you still owe on it, if anything.

7. Are there debts or other facts explaining your financial situation?
“My debts include: (List debt and amount owed)

                                                                                                                                              “
(If you want the court to consider other facts, such as unusual medical expenses, family emergencies, etc., attach another page to
this form labeled “Exhibit: Additional Supporting Facts.”) Check here if you attach another page.

8. Declaration
I declare under penalty of perjury that the foregoing is true and correct. I further swear:
    I cannot afford to pay court costs.
    I cannot furnish an appeal bond or pay a cash deposit to appeal a justice court decision.
My name is                                                                               . My date of birth is :       /         /        .
My address is
                       Street                                            City           State              Zip Code             Country

                                            signed on          /         /      in                          County,
Signature                                                Month/Day/Year              county name                      State


© Form Approved by the Supreme Court of Texas by order in Misc. Docket No. 16-9122
Statement of Inability to Afford Payment of Court Costs                                                                        Page 2 of 2
