                              COURT OF APPEALS FOR THE
                         FIRST DISTRICT OF TEXAS AT HOUSTON

                                          ORDER

Appellate case name:        Maribel Woodard v. McDonald’s Corporation HK
                            Management, Inc d/b/a McDonald/037097 and Manager,
                            McDonalds Restaurant #307097

Appellate case number:      01-17-00204-CV

Trial court case number:    2013-58383

Trial court:                269th District Court of Harris County

       The Clerk of this Court’s March 24, 2017 notice to the district clerk requested an
indigent clerk’s record by April 28, 2017, after appellant had filed a “Statement of
Inability to Afford Payment of Court Costs or an Appeal Bond” (“Statement”), which is
a new affidavit of indigence form approved by the Texas Supreme Court. This
Statement was filed by appellant, Maribel Woodard, in both this Court and the district
court on March 13, 2017. Instead, on April 18, 2017, the district clerk filed an
information sheet in this Court stating that the clerk’s record will not be filed because the
appellant has not made payment arrangements.
       Rule 20.1 provides that a party who files such a Statement in the trial court will
not have to pay costs in the appellate court unless the trial court overruled the party’s
claim of indigence in an order that complies with Texas Rule of Civil Procedure
145. See TEX. R. APP. P. 20.1(b)(1) (amended; eff. Sept. 1, 2016). However, the Court
is unable to determine whether a contest was filed or if the trial court overruled this
claim of indigence in such an order. See id.
       Accordingly, th e Court ORDERS the d i s t r i c t clerk to file a supplemental
clerk’s record containing the attached appellant’s “Statement of Inability to Afford
Payment of Court Costs or an Appeal Bond in Justice Court,” any contests filed, and any
order granting or overruling appellant’s indigence claim. The supplemental clerk’s
record on indigence shall be filed in this Court within 20 days of the date of this order.

      It is so ORDERED.
Judge’s signature: /s/ Laura Carter Higley
                  Acting individually
Date: May 4, 2017
                                                                                                                                                                                    ACCEPTED
                                                                                                                                                                                     2013-58383
                                                                                                                                                                     FIRST COURT OF APPEALS
                                                                                                                                                                             HOUSTON, TEXAS
                                                                                                                                                                          3/13/2017 11:51:42 PM
  NOTICE: THIS DOCUMENT CONTAINS SENSITIVE DATA                                                                                                                           CHRISTOPHER PRINE
                                                                                                                                                                                         CLERK


                                                                                In the       (Ch(,d,.   one}:                                               ••••••


           McDonald1rtorporation
                                                                              ..~?~.!.~-
                                                                                      ~o g~~~~!
                                                                                            ~~~~                I County Court at Law

                                                                                                    IN -
                                                                                                  Justice Court                  FILED
                                                                                                       ----
Defendant,,",K Management, l~~                                         __
                                                                       .__    -.liill.rriS
                                                                              1st COURT OF--APPEALS         Texas
              (Print first ami last nemo of !t1i!/ (XJrocn bf:JIIl[J suea.}
                                                                                  HOUSTON,         - -
                                                                                                --- TEXAS
                                                                               CO(!I!(Y



                                                                                        - - ---- CM ------
                       Statement of Inability to Afford Payment of            3/13/2017
                                                                                      - I11:51:42
                                                                                       -      D        -- PM
                                                                                  ---- VO ------
                             Court Costs or an Appeal Bond                    CHRISTOPHER      --       A. PRINE
                                                                                          ----
 1. Your Information                                                                 ---- Clerk
 My full legal name is: Maribel   Nadina      Wooda~~_~~__ My date of birth is: ~ f 201 1947
                                  First         .-          /Alddf"l           Last                                                       MOmlVD,,},;;;;;;;;
 My address is;        rHomfJ)         5329 Carmen                      Houston, TX 77033-3205
                                           Same as Above
                      (Maifing)

 My phone numberS32-654-1093My
                                                           ,~~~----------------
                                                            email: MaribeIWoodard6@9mail.com
                                                                                                                                               RECEIVED IN
 About my dependents!                  "The people who depend on me financially are listed below.                                        1st COURT OF APPEALS
       Name                                                                                                                                  HOUSTON, TEXAS
 2
                                                                                                                                         3/13/2017 11:51:42 PM
 3                                                   ------_.-._---- --_._ ...                                                           CHRISTOPHER A. PRINE
 4
 5
                                       _
                                           _                    ---- ---~-.-
                                                                           ..-                                                                    Clerk
                                                                                                                          ----_                __
                                                                                                                                              ..      _. __ .-
 6                                 -
                                                                        ------ ----_.-                   ....   --- ..   ----------
 2. Are you represented by legal Aid?
 o 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-
 O 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-
 txJ   I am not represented by legal ald. I did not apply for representation by legal aid.

 3. Do you receive public benefits?
 o I do not receive needs-based public benefits.                          - or •
 ~ I receive these public benefits/government                            entitiements     that are based on indigency:
        rCheck ALL boxes thal apply and iilriiileiJ proof /0 tillS form. such as d                                        ur   (,heck)
 \iIFood stamps/SNAP              TANF !,...-, Medicaid      CHIP       S51    WIC [] MBD
 o  Public Housing or Section B Housing        Low-Income Energy Assistance    Emergen.cy Assistanc_e
 o  Telephone Lifeline            Communi Care via DADS              0 US in Medicare ("Extra Help")
 o  Needs-based VA Pension        Child Care Assistance under Child Care and Development Block Grant
 [J County Assistance, County Health Care, or General Assistance (GA)
 o  Other:



 C Form Approved by the Supreme Court ofTexas by order in Misc. Docket No, HHJ122
                                                                                                                                                    Page 1 012
 Statement of Inebility to Afford Payment ()f Coun Coots
       4. What is your monthly income and income sources?
       "I get this monthly income:
       $_Sl...6.JlQin monthly wages. I work as a Home                                               Health        Providerfor             . f.:3eacon                     Home         Health     Agency
                                                                                            /ot'~f}i!e-'--'--'
                                                                                     ~t~i)tlr                                    w            ";':;:::,;";:t    0f!'~pI0'/er         ~---

       $                   in monthly unemployment. I have been unemployed since
       $   335.94          in public benefits per month.
       S                  from other people in my household each month;                                          (List on!v if otfu;;! memb&/s                  cortniJut()
                          househaid iflCoroo.)

       $   830.00         from 0 RetiremenUPension         Tips, bonuses     0 Disability          WOrker's Camp
                               ~ Social Security            Military Housing D Dividends. Interest, royalties
                               LJ Child/spousal support
                               [J My spouse's income or income from another member Of my household (If 8Vdii<JUe)
       $   545.67          from other jobs/sources of income.           Disability  Insurance       - car payment
       $2,287.6115            my totai 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                                       $750.00
       Bank accounts, other financial assets                                                         Food and household              supplies                                  i500.00·
            Savin~                  ..                                 $    10.00                    Utilities and telephone                                                    $422.12
                                                                      _t...,.
                                                          Clothing and laundry                                                                                                 $"200.00
                                          .-$-~--- ... Medical and dental expenses                                                                                             '$-'50.00 ...
VehiCles (cars, boats)                                    Insurance (life, health, auto, etc.)                                                                                 _~2S91_0.1_
--201.1. Ford Esccspe--                  _1610.00         School and child care                                                                                                s
________           .,_~   .."., "..__ .. Ji. _,.._.._.. _ Transportation, auto repair, gas                                                                                     i200.00
                                          $               Child! spousal support                                                                                               s
Other property (like jewelry, stocks, land.               Wages withheld by court order
        another     house,       etc.)

----------_                              ..._ ..•. .•••......
                                                  ,                   -$---                          Debt payments         paid to;
                                                                      .1__ "._
                                                                             .                           See Attached
                                                                       s
                   Total value of        property,·$'620.00                                                           Total Monthly Expenses
            'iall16 is                                          SId   fu;"IBss   the                             on

 7. Are there debts or other facts explaining your financial situation?
"My debts                include:    (Lmt debt <111(1 amount            o'l<<edl .                         ,      ~                  _.." .
       This does ..not tcskein ..aCCQUntanyunexpec:tedemergencJes                                                                                              .•


  8. Declaration
       I declare    under     penalty      of perl!Jry that the foregoing                           is true and correct       I further swear:
   '-1 I cannot afford to pa....
)(d.                         y court costs.
   'XlI cannot furnish an ap al.bon or
   Mynameis-LLL~~~~~~~~LM~~~--~r---~
       MyaddM6S$             __ ~~~L-~-£~~~~~                                                       __ ~~~LL~~~a=~L-~~~~--,~~~


       ~~

       @FormApproved          by tM Supreme Court of Texas by order in Misc. Docket No 16-9122
                                                                                                                                                                                     Page 2 of2
       Statement of Inability to Afford Payml')nt               of Court Costs
