  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
