### NOTICE: THIS D OCUMENT CONTAINS SENSITIVE DATA

© 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



## Statement of Inability to Afford Payment of

Court Costs o r an Appeal Bond

1. Your Information

My full legal name is : My date of birth is: / /

First Middle Last Month/Day/Year

My address is: (Home )

(M ailing)

________________________________ ________________________________ ___________________

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

r eceived 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 re present me, and the provider determined that I am financially eligible

for representat ion, but the provider could not take my case. I have attached documentati on 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 recei ve 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)

O ther : Cause Number:

(The Clerk’s office will fill in the Cause Number when you file this form)

Plaintiff: In the ( check one) :

(Pri nt first and last name of the person filing the lawsuit

. ) District Court

County Court / County Court at Law

Justice Court And Court

Number

Defendant: Texas

( Print first and last name of the person being sued

. ) County© 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 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: ( L ist only if other members contribute to your

household income

. )

$ from Retirement/Pension Tips, bonuses Disability Worker’s Co mp

Social Security Military Housing Dividends, interest, royalties

Child/spousal support

My spouse’s income or income from another member of my househ old ( I f available)

$ from other jobs/ source s of income

. (D escribe)

$ is my total mo nthly 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,

another house, etc.) Wages withheld by court order

$

$ 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 label ed “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 d eposit to appeal a justice court decision.

My name is

. My date of birth is : / /

.

M y address is

Street City State Zip Code Country

signed on / / in County,

Signature Month/Day/Year county name State