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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/t Number) fj County Court at Law

D Justice of the Peace

Respondent/ County, Texas

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 Court Fees)

You musteither 1)signthis form In You can be prosecuted Ifyou lie on

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 that you have no

ability to pay court fees.

lO&ai

penalty of perjury that the information

provided is true and correct.

O The personwhosigned this affidavit appeared, Inperson,before me,the undersigned notary, 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 ofeighteen (18) years, and1am fully competent to make this affidavit. I am unable to pay court

costs.Thenature andamount ofmyincome, resources, debts, andexpensesare 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) ,

fJ9 Wages: Iwork as a . ydurjob (/He Your employer

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

© "My income amounts are stated below.

SELF EMPLOYED,

-orfor SFI FFMPIOYFD

(a) My monthly net income after taxes are taken out is:

(b) Theamount Ireceive each month in public benefits is;

(c) The amount ofincome 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 Ifothermembers contribute toyour household income.

© TexasLawHetp.org - Affidavit of Indigency, 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

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Page 1 of 2
About 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

ANA UUIJANU Jan % 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 the 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 (if anything).

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 ifyou 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 of a notary public or

•ign and attach a completed "Unsworn Declaration'' form.

Notary flits out this section if you

are signing in front ofo notary.

^ AvvrDate

Notary stamp here /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 Issigning'this Affidavit.

notary's name. •^—^.'-**••—g—Xft—*EV->r.—ffi_-/ES.

©TexasLawHelp.org -Affidavit ofIndigency, FebrUSry^ffT^P^

LINDA CASTRO

MyCommission Expires

March 31, 2018

*^"SEa,"S£:,"SP

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