                                                         05-19-00728-CV
—




      NOTICE: THIS DOCUMENT CONTAINS SENSITIVE DATA
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                                                                                                          Q District Court
                                                                                          “fl                           çajourt at Law
                                                                                                              Justice Cou”
    Defendan/ctflttt
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                                                  In
                                                  of inc poiscn   being ‘:ued     )


                                   Statement of Inability to Afford Payment of
                                                   Court Costs or an Appeal Bond



      My fuN leg name           is,k/teFits;
                                                            flktC
                                                                        :o                Last
                                                                                                                   My date of birth is:            4_i/it te5
                                                                                                                                                   /-.c;SfrDaW ear


       My address is:        iiun,eI                                         ? Jc..cfr-$                  .__%                  Q
                           (a4rcj              .     flfl    C)
       My phone number-$f
                                       fl-I-,           g3.
                                                             My email:                77 /
       About my dependents: The people who depend on me financially are listed below.
                                                                                                                                     Re/abc    is/ic) to   Me


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        3
        4
        5
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                                                                                  1%

       2. Are you represented by L al Aid?
       LI 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


       [3     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 tating this.
       or-
               am not represented by legal aid. I did not apply for representation by legal aid.

       3. Do you receive public benefits?
       [H’not receive needs-based public benefits. - or -
       Li I receive these public benefitslgovernment entitlements that are based on indigency: as a copy of an eflq’Uilny loin, ortheck I
               iCneck   sQL lroes I/at   apply ad at/ad’ proct       to this ibm,     Slit/I

        J     Food stamps)SNAP            0 TANF L Medicaid IJ CHIP           SSI D W1C H MBD
        LI    Public Housing or Section 6 Housing U Low-Income Energy Assistance El Emergency Assistance
        [ii   Telephone Lifeline                       LI
                                            Community Care via DADS           LIS in Medicare (Extra Help)
        U     Needs-based VA Pension LI Child Care Assistance under Child Care and Development      ck Grant

        r, gr         rstcounttt7t
                                                   or General As&stance




        © Form Approved by the Supreme Court of Texas by order in Misc. Docket No. 16-9122
        Statement of fnabsfity to Afford Payment of Court Costs                                                                                            Page 1 of 2
4. What is your monthly income and income sources?
“I get this monthly income:
           C in monthly wages. I work as a
                                                           [7    rev
                                                            ourjci)  t,,Ie   “°1lr        a—        for      i9I4c /hc
                                                                                                             SU    rl;Jm3er
                                                                                                                                                    a1L1
                in monthly unemployment. I have been unemployed since (datel
                      public benefits per month.
                      ‘mother people in my household each month: (Lstmityfoiha’inemheiscontnht&wym’r
                      i50B0’d   :i;corne.)
                 rom     [J
                         Retirement/Pension El Tips, bonuses      fl Disability      [J Worker’s Comp
                        Social Security          Military Housing El Dividends, interest, royalties
                        Child/spousal support
                     U My spouse’s income or income from another member of my household (If avanable)
                 from other jobs/sources of income. (Oesaim&
s_i 0 0          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                                 $                 Ito                   Rent/house payments/maintenance                      sQ
Bank accounts, other financial assets                                        Food and household supplies
                                                                             Utilities and telephone                              s%LO
        7/                                                                   Clothing and laundry                                 $0
       //                                         $     ho                   Medical and dental expenses                          2-- OQ
Vehiclgs (ca, boats) ;nreke and yea’)                                        Insurance (life, health, auto, etc.)                 $frC
                                                                             School and child care                                $ V?0
                                       $v0                                   Transportation, auto repair, gas
                                       $140                                  Child / spousal support                              $
Other property (like jewelry, stocks, land,                                  Wages withheld by court order
 another house, etc.)
         ,‘\                                      $         V                Debt payments paid to:       (List’                  svtO
                                                                                                                                  s1’O
    VL’  T al value of property
 The vaiue is the amount the
                                              -      $j7 p
                                    torn would sell for
                                                                                         Total Monthly Expenses
                                                      les lhe urn owl you sNI owe on d.. it a nyl 111)0
                                                                                                                                  $
                                                                                                                                 —$

7. Are there debts or other facts explaining your financial situation?
“My debts include: (List deaf and anountowedj    j /1       • fl
                                                                     f/I
                                                                     vu                    I
if you want the court to consider othcr ñ2cts such as unusual medical expens..s, family erne,genc,os cm. attacl; a,indlcr page to
this 1dm, laPsed Exh,bfl Adadianal Supporting Facts.] Chock hem if you attach another page.

8. Decla$ien—
I dØefunder penalty of perjury that the foregoing is true and correct. I further swear
ff1 cannot afford to pay court costs.
Li I cannot furpish n a peal bond or pay a ca d p it to pp al a justice court decision.
Mynameis7+LeVInZt                                     2Z—? I
                                                 /4 t_,lc           My date of birth is;
My addr        s is     ‘t—Y          ?z5      C’                                       -          -t
                                                                                                                    ZIP   coce


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© 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
