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 in Justice Court 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