                                    COURT OF APPEALS FOR THE
                               FIRST DISTRICT OF TEXAS AT HOUSTON

                                                ORDER

Appellate case name:      $1,941.00 US Currency v. The State of Texas

Appellate case number:    01-17-00516-CV

Trial court case number: 16-1411-C277

Trial court:              277th District Court of Williamson County

Appellant, Mark Allen Oliver, filed a letter in this Court stating that he is incarcerated and indigent.
The court reporter has advised this Court, however, that appellant has neither requested preparation of
the reporter’s record nor made arrangements to pay for the reporter’s record.
Effective September 1, 2016, the rules require a party who is unable to pay the costs of appeal to file a
Statement of Inability to Afford Payment of Court Costs (“Statement of Inability form”). See TEX. R.
CIV. P. 45; TEX. R. APP. P. 20.1. A Statement of Inability form is attached to this order.
If appellant wishes to proceed without paying costs or fees associated with the preparation of the
appellate record, he must comply with Rule 145(b) and file the Statement of Inability form in the trial
court. See TEX. R. CIV. P. 145(b). Moreover, Appellant must ask the trial court clerk to prepare and file
a supplemental clerk’s record within 14 days of the date of this order, and that record should contain
appellant’s Statement of Inability form.
It is so ORDERED.

Judge’s signature: /s/ Jennifer Caughey
                    Acting individually      Acting for the Court


Date: December 12, 2017
NOTICE: THIS DOCUMENT CONTAINS SENSITIVE DATA
© 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
                                   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:
                             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


And

Court Number


County Court / County Court at Law Justice Court

 Defendant:                                                                                                        Texas
             (Print first and last name of the person being sued.) County
    © 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
    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, another house, etc.)


   Wages withheld by court order

    $

                                                          $                         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
                                           signed on        /       /           in                     County,
Signature                 Street                            Month/Day/Year
                                                                       City county name
                                                                                    State              StateZip Code
                          Country
