                                                                                                                                                      ACCEPTED
                                                                                                                                                 13-14-00716-cv

                                            W               \u ^vu cvy                                                            THIRTEENTH COURT OF APPEAL
                                                                                                                                          CORPUS CHRISTI, TEXAS
                                                                                                                                             1/13/20159:21:08 PM
                                                                                                                                                DORIAN RAMIREZ
                                                                                                                                                           CLERK

 NOTICE: THIS FORM CONTAINS SENSITIVE DATA.
                             Cause Number
                                              (The Clerk's office wW fill inthe Cause Number when youm this form.)
                                                                        In the (check one}:
Petitioner/
Plaintiff                                                                               •     District Court
                                                                       {Cou/t Number) fj County Court at Law
                                                                                         D Justice of the Peace

Respondent/                                                                                                         County, Texas
Defendant                                                              (County)

                                                        Affidavit of Indigency
                                                        (RequesttoNotPay Court Fees)
   Use this form to ask the court not to             You musteither 1)signthis form In                 You can be prosecuted Ifyou lie on
   charge you for court fees. This form is           front of a notary public or 2) sign this          this form.
                                          form and sign and attach a completed The court may or may notapprove this
   also called an "Affidavit of Inability to
   Pay Court Costs" or a "Pauper's Oath." "Unsworn Declaration" form. By       requestto notpaycourt fees. Thecourt
   You can only use this form If: (1) you            signing in front ofa notary, you swear            mavorcjer yout0 answerquestions
   get public benefits because you are               under oath that the information                   aD0Ut yourfinances at a hearing. At
   poor or (2) you can't pay court fees.             provided is true and correct. By                  that hearing you will have to present
   The information you give on this form             signing and attaching an "Unsworn                 evidence to theJudge ofyour income
   must be current, complete, true and               Declaration"1 form, you declare under             ancj expenses to prove that you have no
   correct.                                          penalty of perjury that the information ability to pay court fees.
                                                     provided is true and correct.
   O The person who signed this affidavit appeared, In person, before me,the undersigned notary, and stated
   under oath:
    "My name is        VICTOR QUIJANQ                                                    Mv phone number Is ( Qfi6&J2254?
    "My mailing address is. _        lO&ai
    "Myemail address is               TARPEST@HOTMAIL.COM
    "I am above theage ofeighteen (18) years, and1am fully competent to make this affidavit. I am unable to pay court
    costs. The nature and amount ofmyincome, resources, debts, and expensesare described inthisform.
    Check ALL boxes thai apply and fill in the blanks describing the amounts and sources ofyour Income.
    © "I receive these public benefits/government entitlements that are based on indigency:
    • SSI          DWIC          CS;FoodStamps/SNAP                   DTANF           [^Medicaid             • CHIP              QAABD
    D Needs-based VA Pension         O County Assistance, County Health Care, orGeneral Assistance (GA)
    • LIS in Medicare ("Extra Help")    • Community Care via DADS         • Low-Income Energy Assistance
    D Emergency Assistance        • Child Care Assistance under Child Care and Development Block Grant
    •   Public Housing        • Other: (Describe)                                             .              :
                    If you receive enyofthoabove public benefits, attach proof, andlabel It 'Exhibit Proof ofPublic Benefits"
    © "My income sources are stated below. (Check bU that apply)
    • Unemployed since: (date)                                   ,                              -or-

    fJ9 Wages: I work as a                                                                      for            . FFMPIOYFD
                                                                                                             SFI
                               SELF EMPLOYED,                  ydurjob (/He                                            Your employer
    • Child/spousal support G My spouse's Income or Income from another member of myhousehold (if available)
    • Tips, bonuses • Military Housing • Worker's Comp G Disability O Unemployment G Social Security
    G Retirement/Pension Q Dividends, interest, royalties G 2nd Job or other income:
                                                                                                                            (describe)
     © "My income amounts are stated below.
     (a) My monthly net income after taxes are taken out is:                                       Total income after,taxes -#           1.6QQ
     (b) Theamount I receive each month in public benefits is;                                         Total amount received -t      1SL
     (c) The amount ofincome from other people in my household is:'                                    Total amount received -t

     (d) The amount Ireceive each month from othersources Is:                                          Total amount received ^

     (e) My TOTAL monthly Income is                                                   Add all sources of income above-*           =r •^00-
            'List tin's Income only Ifothermembers contribute to your household income.
                                                                                                                                             Page 1 of 2
  © TexasLawHetp.org - Affidavit of Indigency, February 2014
   About my dependents: "The people who depend on me financiallyare listed below:
        Name                                                                                               Age                 Relationship to Me
                                                                                                                                         WIFE
   1 MARIA AMAYA                                                                                            53_
   2     ESTEFANIA QUUANO                                                                                  2A.                     OAlffiHTFR
   3     .IFSIISOUI.IANO                                                                                   43-                    -SON-
   4    JUAN QUUANO
             QUI                                                                                                                    i©N-
             Jan
         ANA UUIJANU                                                                                        %
                                                                                                                                   DAUGHTER
   6


 © "My property includes:                                Value*                  ©"My monthlyexpenses are:                                  Amount

 Cash                                                                             Rent/house payments/maintenance                         689
                                          JL5G
 Bank accounts, other financial assets (List)                                     Food and household supplies                             600
                                                  $      0                        Utilities and telephone                            $    250
                                                   $                              Clothing and laundry                               $_JL
                                                   £                              Medical and dental expenses                        E_Q-
 Vehicles (cars, boats) (List make andyear)                                       Insurance (life, health, auto, etc)
  WINnSTARflR                                      $ 1500                         School and child care
                                                   $                              Vehicle payments
                                                                                  Gas, bus fare, auto repair
                                                                                                                                          •ttr
                                                   $                              Child / spousal support
 Real estate (house or land) (Do not list the house you live in.)                 Wages withheld by court order
                                                   $ 0                            Debt payments
                                                   $                              Other expenses (Describe)
 Other property (likejewelry, stocks, etc.) (Describe)
                                                   $0
                                                   $0


                Total value of property -*          = $ 1650                |                      Total monthly Expenses ->             = $1 fiiann
   "The value is ihe amount the item would sell for less the. amount you still owe on tl (if anything).

   t) "My debts include: List debt and amount owed.                 .



 Tolist any otherfacts you want the court lo know, such as unusualmedical expenses, family emergencies, etc., attach another
 page to this form and label it"Exhibit: Additional Supporting Facts." Check here ifyou attach another page.Q
 @k"l am unable to pay court costs. I verify that the statements made in this affidavit are true and correct."
       Your Sidnatui          Ygit must either: 1) sign thisform In front of a notary public or
       2) sign mis                •ign and attach a completed "Unsworn Declaration'' form.
                                                                                                                        ^ Avvr
        Vow                                                                                                                              Date

                                                                        Notary flits out this section if you
   Stattfof Texas                                                       are signing in front ofo notary.
                                                                                                                               Notary stamp here
   County of                       /no-TOs*
   Prim tho nameof county where this Affidavit is notarized.            I

   Sworn to and s]rfbsc?)ibed before me today,                   ///•-? / ' O              .by t/fcJo/ ^Qnu£if),<),0io>/)o.
                                                                                                     Printname of persdn who Is signing'this Affidavit.
                                                             •^—^.'-**••—g—Xft—*EV->r.—ffi_-/ES.
                                                                                                              notary's name.


                                                                                   LINDA CASTRO
                                                                                My Commission Expires
                                                                                   March 31, 2018
                                                                                                                                                          Page 2 of 2
©TexasLawHelp.org - Affidavit ofIndigency, FebrUSry^ffT^P^          *^"SEa,"S£:,"SP
