# W \u ^vu cvy ACCEPTED 13-14-00716-cv THIRTEENTH COURT OF APPEAL CORPUS CHRISTI, TEXAS 1/13/20159:21:08 PM DORIAN RAMIREZ CLERK NOTICE: THIS FORM CONTAINS SENSITIVE DATA.

Petitioner/ Plaintiff Cause Number (The Clerk's office wW fill inthe CauseNumber when youm this form.) In the (check one}: • District Court 

### {Cou/tNumber) fj County Court at Law D Justice of the Peace County, Texas Respondent/ Defendant

Use this form to ask the court not to charge you for court fees. This form is also called an "Affidavit of Inability to 

### Pay CourtCosts" or a "Pauper's Oath." You can only use this form If: (1) you get public benefits because you are poor or (2) you can't pay court fees. The information you give on this form must be current, complete, true and correct. (County) 

### Affidavit of Indigency (RequesttoNotPay CourtFees) 

### You musteither 1)signthis form In You can be prosecuted Ifyou lieon front of a notary public or 2) sign this this form. 

### form andsign andattach a completed The court may ormay notapprove this "Unsworn Declaration" form. By requestto notpaycourt fees. Thecourt signing in front ofa notary, youswear mavorcjer yout0 answerquestions under oath thatthe information aD0Ut yourfinances at a hearing. At provided is true and correct. By that hearing you will have to present 

### signing and attaching an "Unsworn evidence to theJudge ofyour income Declaration"1 form, you declare under ancj expenses to prove thatyou have no ability to pay court fees.


# lO&ai penalty ofperjury that the information provided is true and correct. 

### O The personwhosignedthis affidavit appeared, Inperson,before me,the undersignednotary, and stated under oath: 

## "My name is VICTOR QUIJANQ Mv phone number Is ( Qfi6&J2254? "My mailing address is. _ "Myemail address is TARPEST@HOTMAIL.COM 

### "I am above theage of eighteen (18) years, and1am fully competent to make this affidavit. Iam unable to pay court costs.Thenature andamount ofmyincome, resources, debts, andexpensesare described inthisform. CheckALL boxes thai apply and fill in the blanks describing the amounts and sources of yourIncome. 

### © "I receive these publicbenefits/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)

. : Ifyou receive enyofthoabove public benefits, attach proof, andlabel It 'Exhibit ProofofPublic Benefits" © "My income sources are stated below. (Check bU that apply)

• Unemployed since: (date) , fJ9 Wages: Iwork as a

. ydurjob (/He Your employer


### • Child/spousal support G My spouse's Income orIncome from another member ofmyhousehold (ifavailable)


## • 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 otherincome: © "My income amounts are stated below. SELF EMPLOYED, -orfor SFI FFMPIOYFD



### (a) My monthly netincome after taxes are taken out is: 

### (b) Theamount Ireceive each month inpublic benefits is; 

### (c) The amount of income from other people in my household is:' (d) The amount Ireceive each month from othersources Is: (e) My TOTAL monthly Income is 'List tin's Income only If other members contribute toyour household income. © TexasLawHetp.org

- Affidavit ofIndigency, February 2014 (describe) Total income after,taxes -#

Total amount received -t Total amount received -t Total amount received ^ Add all sources ofincome above-* 1.6QQ 1SL



# = r •^00- Page 1 of 2About my dependents: "The people who depend on me financiallyare listed below: Name Age 

## 1 MARIA AMAYA 53_ Relationship to Me WIFE 2 ESTEFANIA QUUANO 3 .IFSIISOUI.IANO 4 JUAN QUUANO

6 2A. OAlffiHTFR 43- -SONQUI 

### Jan ANA UUIJANU 

## % i©NDAUGHTER


### © "My property includes: Cash Value* ©"My monthlyexpenses are: Rent/house payments/maintenance JL5G Bank accounts, other financial assets (List) $ 0 $ £ Food and household supplies Utilities and telephone Clothing and laundry Medical and dental expenses Vehicles (cars, boats) (List make andyear) WINnSTARflR $ 1500 $ Insurance (life, health, auto, etc) School and child care Vehicle payments Gas, bus fare, auto repair $ Child / spousal support Real estate (house or land) (Do not list t he house you live in.) 

### $ 0 $ Wages withheld by court order Debt payments Other expenses (Describe) Other property (likejewelry, stocks, etc.) (Describe) 

### $0 $0 Total value of property -* 

## =$ 1650 | Total monthly Expenses -> "The value is ihe amount the item would sell for less the. amount you still owe on tl (ifanything). t) "My debts include: List debt and amount owed. . Amount 689 600 $ 250 $_JL E_Q-

•ttr



### = $1 fiiann

Tolist any otherfacts you want the courtlo know, such as unusualmedicalexpenses, family emergencies, etc., attach another 

### page to this form and label it"Exhibit: Additional Supporting Facts." Check here if you attach anotherpage.Q @k"l am unable to pay court costs. I verify that the statements made in this affidavit are true and correct." Your Sidnatui 2) sign mis

Vow Stattfof Texas County of Ygit must either: 1) sign thisform In front ofa notary public or •ign and attach a completed "Unsworn Declaration'' form.

Notary flits out this section if you are signing in front ofo notary. 

# ^ Avvr Date Notary stamp here /no-TOs* Prim tho nameofcounty 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. notary's name. •^—^.'-**••—g—Xft—*EV->r.—ffi_-/ES.



### ©TexasLawHelp.org

-Affidavit of Indigency, FebrUSry^ffT^P^ LINDA CASTRO MyCommission Expires March 31, 2018
*^"SEa,"S£:,"SP Page 2 of 2