FILED lN
\ST couat oF APPEALS
HQUSTO!‘ `\'EX 05

DEC -7 2015

NO_ H/// §:.OWQ g% G::a::rop§'_.?/:\ \»’F\lr\ii:W

[leave blanl<; case number will be assigned later]

[insert caption used in appeal i..e,
[name of appellant] v. [name of appellee]]
M /////f /a///‘?//‘f //5 /Mvd/JH/W%Q/ cary
Affidavit of lndigence
[sample; for use in appeals; file with trial-court clerk
with or before filing notice of appea|]

//fQ/f?&§

l, [appellant’s name], swear [or affirm] the following: M,,_`

/_,-_-__'_"_`)
\

1. l have filed an appeal in the case described above.

Tc@n )70/` _ _ _ _
2.i-l~aan pay the following amount of court costs in this appeal, which
includes the $175 filing fee, the $‘l 0 or $15 filing fee for each motion l may file,
the trial-clerk’s fee for the clerk’s record, and the Court reporter’s fee for the

reporter’s record1 if any: [describe in detail amount, if any, you can pay].

3. The nature and amount of my current employment income is
[describe in detai|]l ,

4. The nature and amount of my current government”entitlement income
is [describe in detai|]£1 ~755’/;.{/” /14//»'¢!~

5. The nature and amount of my current income, other than that
described in my answers to 3 and 4 above, is [describe in detail]. ///

6. T e income of my spouse is [describe in detail]. lVly spouse's income
[is o@ available to me.

7. l own the following real property: [describe in detai|]. /{/7//£

8. l own the following personal property: [describe in detail]./V///E

9. l have the following amount of cash: [describe in detail]./@/J

10. l have the following amounts of funds on deposit that l may
withdraw: [describe in detail]. ,g/

11. l have the following assets, other than those described in my
answers to 3 through 10 above: [describe in detail].,Q/'

12. l have [provide number] dependants. lVly relationship to each of
them is [describe in detail]. 3

13. The nature and amount of my debts are [describe in detail]. @/

14. The nature and amount of my monthly xpenses are [describe i
deming/953 WW+ //%M/Z@ MQ/a/r§?/@A “/??a¢W¢a/a,,§ao

15. iviy ability to obtain a ioan for court costs is [describe in detail]. [/y//a/

16. An attorney [is or is not] providing free legal services to me without a
contingent fee.

17. An attorney [has or‘agreed to pay or advance court costs.

18. [lf the trial-court proceedings were recorded electronicallyg or
lack] the skills and access to equipment necessary to prepare the appendix
required by Texas Ru|e of Appe|late Procedure 38.5(d).

flotilla lot/ii

[Signature of party claiming indigence, who is
swearing or affirming information given above;
must be signed in presence of person described
below]

 

Certificate of Oath or Affirmation

On this date, l administere he bo e ath or ffir tio 0
person named above. l ama W&¢%: %YW
and am authorized to administer an oath or affirmation pursuant to Texas
Government Code section 602.002, 602.003, 602.004, or 602.005. lfl have a
seal of office that l am required by law to affix to documents when
administering an oath or aermation, then l have included an original

impression of my ochial seal below.

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.io uJ,eo Buuei,siuii.upe uosied 40 ‘Aue ,ti ‘|ees |eiog,io to uo!sseidtui |euiBi.io]

leieol

,5/% ~‘ w /t§/

 

[uogeuu!ge
Jo uteo Buuei,siuiiupe uosied 40 eJnJ,euB!S]

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