WR No. 20,644-_·_ 

Ex parte In the Texas Court 

Paul Larson Criminal Appeals 

RECEI.YED IN 

cause Nos. 449008-C, 44900,8-D, 465007-C, & 465007-D .COURftW~'R1MfM<~CAPPEALS 

WR 20,644-04, WR 20,644-05, WR 20,644-06, WR 20,644-07, & WR 20644-08 

· APR 012015 PETITION FOR WRIT OF ERROR/BILL OF REVIEW 

COMES NOW, Paui Larson, Petitioner (hereafter Larson),· britg~~1,~?§~~·t~~~rk Honorable Court Larson's Petition for Writ Of Error/ Bill Of Review; and, in support 

thereof, will show: 

JURISDICTION 

A Bill of Review is a: 

"[p]roceeding in equity brought for purpose of reversing or correcting prior judgment of ... court 

after judgment has become final. Rogers v. Searle, Tex.Civ.App., 533 S.W.2d 433, 437. It is in the 

nature of a writ of error. A "bill of review," or a bill in the nature of a bill of review, are of three 

classes; those for error appearing on the face of the record, those for newly discovered evidence, 

and those "for fraud impeaching the original transaction. Such bills are peculiar to courts of 

equity." Black's Law Dictionary, Fifth Edition, page 151 

Larson brings this Action based on "error appearing on the face of the record" 

and/or "for fraud impeaching the original transaction." If the entire record of Cause 

Numbers 449008-C, 449008-D , 465007-C, and 465007-D had been brought before this 

Honorable Court {due to the restraints on Larson's abilities to copy and/or purchase 

copies of the District Clerk's files, Larson has no knowledge of what records were 

forwarded to this Honorable Court), then the fact a subsequent Court Order filed with 

this Honorable Court from the 263rd District Court, after Larson filed for Mandamus 

Action, neither referred to nor negated an earlier Order in these Causes which stipulated 

that there were unresolved issues which were to be decided by the Court, requiring 

further Findings of Facts and Conclusions of Law (copies attached), then error does 

appear on the face of the record. However, if, in fact, this allegation (of Fact) is not 

evident from the face of the Records received from the Harris County District Clerk's 

Office in these Cause Numbers, the extrinsic fraud has been perpetrated upon the 

Petitioner and this Honorable court "impeaching the original transaction," i.e., the denial 

of Larson's Application For Writ Of Habeas Corpus and/or Writ Of Mandamus. 

The State perpetrated further Fraud upon the Petitioner and this Honorable 

Court by falsely designating the June 12, 2014 Answer "Original," and intentionally 

mailing Larson's copy to the wrong address, delaying delivery for a month. 
PRAYER FOR RELIEF 

Larson PRAYS this Honorable Court GRANT Larson's Bill Of Review, Review the entire 

Habeas Record, Ordering-if necessary-the Harris County District Clerk's Office to provide 

both the Honorable Court and the Petitioner the Complete Habeas Corpus Files in the above 

and Foregoing Trial Court Cause Numbers and, thereafter, GRANTING the Relief origingally 

PRAYED for in Larson's Applications For Writ Of Habeas Corpus; for thus Doth Petitioner PRAY. 

CERTIFICATE OF SERVICE 

Service has been accomplished by mailing a true and correct copy of the 

foregoing instrument (Bill of Review) to the following address: Honorable Linda 

Garcia, Assistant District Attorney; 1201 Franklin St., suite 600; Houston, Texas 

@ 77002, on this, the t2~ day of ('()~ 2015. 

Signed On This The #-day of {~ ~'} , 201S. 

UL LARSON, Petitioner ProSe 

9 Bucan Street, #I 

Houston, Texas 77076-2451 

SUBSCRIBED AND SWORN TO BEFORE ME, the undersigned Notary Public, on this 

~of R;b~ , 2015 

My Commission Expires: 

* 

NOTARY PUBLIC 

----

1 "t(A(C ....j-~ 
Petitioner/ ~ / - \ 

Plaintiff .--fAuL 

----------~--------~--~---

A-t-t.AN ~SotJ 

In the (check one): 

0 lili8t1ic+Court of~ Ml.N bC... kPMLS 

Respondent/ 

Defendant 

-;:::----:--;-:--;--,-

(Court Number) 0 County Court at Law 

0 Justice of the Peace 

(County) 

Affidavit of lndigency 

(Request to Not Pay Court Fees) 

County, Texas 

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 Court Costs" 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. 

You must either 1) sign this form in 

front of a notary public or 2) sign this 

form and sign and attach a completed 

"Unsworn Declaration" form. By 

signing in front of a· notary, you swear 

under oath that the information 

provided is true and correct. By 

signing and attaching an "Unsworn 

Declaration" form, you declare under 

penalty of perjury that the information 

provided is true and correct. 

You can be prosecuted if you lie on 

this form. 

The court may or may not approve this 

request to not pay court fees. The court 

may order you to answer questions 

about your finances at a hearing. At 

that hearing you will have to present 

evidence to the judge of your income 

and expenses to prove that you have no 

ability to pay court fees. 

<D The person who signed this affidavit appeared, in person, before me, the undersigned notary, and stated 

under oath: J' 

"My name is :A-ILS-~ 

"My mailing address is 

"My email address is 

"I am above the age of eighteen (18) years, and I am fully competent to make this affidavit. I am unable to pay court 

costs. The nature and amount of my income, resources, debts, and expenses are described in this form. 

Check ALL boxes that apply and fill in the blanks describing the amounts and sources of your income. 

® "I receive these public benefits/government entitlements that are based on indigency: 

D SSI 0 WIC ~ Food Stamps/SNAP D TANF D Medicaid D CHIP D AABD 

D Needs-based VA PenSion D County Assistance, County Health Care, or General Assistance (GA) 

0 LIS in Medicare ("Extra Help") 0 Community Care via DADS D Low-Income Energy Assistance 

D Emergency Assistance 0 Child Care Assistance under Child. Care and Dev~ment Blo5t Grant 

0 Public Housing ~ Other: (Describe) 5 • S. fJ • /2e:n Rr:.t'\ ~tJ I --t:5e.t..J E-F I I ..SO 

If you receive any of the above public benefits, attach proof and label it "Exhibit: Proof of Public Benefits" 

® "My income sources are stated below. (Check all that apply) 

----------------------------- -orfor 

0 Unemployed since: (date) 

0 Wages: I work as a 

--------------;-;Yo,--u-r-,-jo-:-b-;tt:;-;.tle___________ Your employer 

0 Child/spousal support D My spouse's income or income from another member of my household (if available} 

D Tips, bonuses D Military Housing 0 Worker's Comp 0 Disability 0 Unemployment ~ocial Security 

D Retirement/Pension 0 Dividends, interest, royalties 0 2nd job or other income: , · (describe) ® "My income amounts are stated below. 

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

{b) The amount I receive each month in public benefits is: 

Total income after taxes --+ 

Total amount received --+ 

Total amount received--+ 

$ t3t:4 G~ 

+ $ liDo.£_ 

(c) The amount of income from other people in my household is:* 

(d) The amount I receive each month from other sources is: Total amount received--+ 

(e) My TOTAL monthly income is Add all sources of income above-+ 

*List this income only if other members contribute to your household income. 

© TexaslawHelp.org- Affidavit of lndigency, February 2014 

+ "-$ _ _,tzfo=..-_ 

+ ":--$ ____,...,~<---- = $ rs2.~~ 

Page 1 of 2 
® About my dependents: 'The people who depend on me financially are listed below: 

Na7 Age 

1 l~b JJE. 

Relationship to Me 

2 --------------------------------------------------------------------------

3 --------------------------------------------------------------------------

4 --------------------------------------------------------------------------

5 ------------------------------------------------------------~-------------- 6 

® "My property includes: Value* 

Cash $ 4SeE 

Bank accounts, other financial assets (List) 

{!.ij-prsFL- ~~. $ ~ 

$ 

$ 

Vehicles (cars, boats) (List make and year) 

$ 

$ 

$ 

Real estate (house or land) (Do not list the house you live in.) 

$ 

$ 

Other property {like jewelry, stocks, etc.) (Describe) 

$ 

$ 

CV"My monthly expenses are: 

Rent/house payments/maintenance 

Food and household supplies 

Utilities and telephone 

Clothing and laundry 

Medical and dental expenses 

Insurance {life, health, auto, etc) 

School and child care 

Vehicle payments 

Gas, bus fare, auto repair 

Child I spousal support 

Wages withheld by court order 

Debt payments 

Other expenses (Describe) 

Amount 

$ fs()o ~ Ltno . $ 'Z.Dote MD 

$ t../ z.. ~ fY'{c). 

$ Z.S'~ /VIo 

$ ~0~ 

$ 

$ 

$ 

$ :s?J ~ 'f#o· 

$ 

$ 

$ ~~ 

$ 

$ 

$ 

$ 

Total value of property ~ I= $ l \ D ~ Total monthly Expenses ~ I._=--'-$ ________ _, *The value is the amount the item would sell for less the amount you still owe on it (if anything). 

® "My debts include: List debt and amount owed. ~~il ~s; 3oo ~ /Mo # 

To list any other facts you want. the court to know, such as unusual medical expenses, family emergencies, etc., attach another 

page to this form and label it "Exhibit: Additional Supporting Facts." Check here if you attach another page.O 

® "I am unable to pay court costs. I verify that the statements made in this affidavit are true and correct." 

®Your Signature. You must either: 1) sign this form in front of a notary public or 

2) si is for ,and sign and attach a completed "Unsworn Declaration" form. 

~ 

I 

Date 

State ofTexas 1-tC. ."> D 'S 

County of U(<...... ~ \.; . Print the name of county where this Affidavit is notarized. 

Sworn to a~ed before me today, ;;?-. .... J_S-CS , by 

I; ~ ¥"1 ~ Date 

N~S~:;> Pri t name of person who is signing this Affidavit. ·-

NOT the notary's name. 

Page 2 of2 

© TexaslawHelp.org- Affidavit of lndigency, February 2014 
.·. 

WR No. 20,644-__ 

Ex parte In the Texas Court 

Paul Larson Criminal Appeals 

Cause Nos. 449008-C, 449008-D, 465007-C, & 465007-D Austin, Texas 

WR 20,644-04, WR 20,644-05, WR 20,644-06, WR 20,644-07, & WR 20644-08 

PETITION FOR WRIT OF ERROR/BILL OF REVIEW 

COMES NOW, Paul Larson, Petitioner (hereafter Larson), bringing before this 

Honorable Court Larson's Petition for Writ Of Error/" Bill Of Review; and, in support 

thereof, will show: 

JURISDICTION 

A Bill of Review is a: 

"[p]roceeding in equity b~ought for purpose of reversing or correcting prior judgment of ... court 

after judgment has become final. Rogers v. Searle, Tex.Civ.App., 533 S.W.2d 433, 437. It is in the 

nature of a writ of error. A "bill of review," or a bill in the nature of a bill of review, are of three 

classes; those for error appearing on the face of the record, those for newly discovered evidence, 

and those "for fraud impeaching the original transaction. Such bills are peculiar to courts of 

equity." Black's Law Dictionary, Fifth Edition, page 151 

Larson brings this Action based on "error appearing on the face of the record" 

and/or "for fraud impeaching the original transaction." If the entire record of Cause 

Numbers 449008-C, 449008-D , 465007-C, and 465007-D had been brought before this 

Honorable Court {due to the restraints on Larson's abilities to copy and/or purchase 

copies of the District Clerk's files, Larson has no· knowledge of what records were 

forwarded to this Honorable Court), then the fact a subsequent Court Order filed with 

this Honorable Court from the 263rd District Court, after Larson filed for Mandamus 

Action, neither referred to nor negated an earlier Order in these Causes which stipulated 

that there were unresolved issues which were to be decided by the Court, requiring 

further Findings of Facts and Conclusions of Law (copies attached), then error does 

appear on the face of the record. However, if, in fact, this allegation (of Fact) is not 

evident from the face of the Records received from the Harris County District Clerk's 

Office in these Cause Numbers, the extrinsic fraud has been perpetrated upon the 

Petitioner and this Honorable court "impeaching the original transaction," i.e., the denial 

of Larson's Application For Writ Of Habeas Corpus and/or Writ Of Mandamus. 

The State perpetrated further Fraud upon the Petitioner and this Honorable 

Court by falsely designating the June 12, 2014 Answer "Original," and intentionally 

mailing Larson's copy to the wrong address, delaying delivery for a month. 
PRAYER FOR RELIEF 

Larson PRAYS this Honorable Court GRANT Larson's Bill Of Review, Review the entire 

Habeas Record, Ordering-if necessary-the Harris County District Clerk's Office to provide 

both the Honorable Court and the Petitioner the Complete Habeas Corpus Files in the above 

and Foregoing Trial Court Cause Numbers and, thereafter, GRANTING the Relief origingally 

PRAYED for in Larson's Applications For Writ Of Habeas Corpus; for thus Doth Petitioner PRAY. 

CERTIFICATE OF SERVICE 

Service has been accomplished by mailing a true and correct copy of the 

foregoing instrument (Bill of Review) to the following address: Honorable Linda 

Garcia, Assistant District Attorney; 1201 Franklin St., suite 600; Houston, Texas 

77002, on this, the ;t~l> day of fJ?f!RCII , 2015. 

Signed On This The JF" day of Fe-bwMt , 2015. 

UL LARSON, Petitioner ProSe 

9 Bucan Street, #I 

Houston, Texas 77076-2451 

SUBSCRIBED AND SWORN TO BEFORE ME, the undersigned Notary Public, on this 

~of fd,~ 2015 

My Commission Expires: 

-::::::> 

* 

NOTARY PUBLIC 

----

( &tf/--.(C ..._;2.. ~ 
( 

EX PARTE 

§ HARRIS COUNTY, TEXAS 

STATE'S·MOTION REQUESTING DESIGNATION OF ISSUES 

The State of Texas, by and through its Assistant District Attorney for Harris County, 

requests that this Court, pursuant to TEX. CODE CRIM. PROC. art. 11.07, §3(d), designate that the 

following issues need to be resolved in the instant proceeding: whether the applicant is being 

illegally denied credit for time spent on supervised release and whether the parole board has 

unlawfully revoked his supervised release. 

Service has been accomplished by mailing a true and correct copy of the foregoing 

instrument to the following address: 

Paul Allan Larson 

9 Bucan Street #1 

Houston, Texas 77076-2451 

SIGNED this lth day of August, 2013. 

Respectfully submitted,. 

Linda Garcia 

Assistant District Attorney 

Harris County, Texas 

1201 Franklin, Suite 600 

Houston, Texas 77002 

(713) 755-6657 

(713) 755-5809 (fax) 

Texas Bar I.D. #00787163 
Cause No. 465007-C 

BY,: PAF.TE JN THE ?.63RD DTSTPJCT COURT 

§ 

.l-' ALJL Ai..LAi'l: LARSON, 

Applicant· § HARRIS COUNTY, TEXAS 

STATE'S PROPOSED ORDER DESIGNATING ISSUES 

Having reviewed the applicant's petition for writ of habeas corpus, the Cou..-1 finds that 

the following issues need to be resolved in the instant proceeding: whether the applicant is being 

illegally confined pursuant to a parole warrant and whether the parole board ha~ unlawfully 

imposed conditions on his mandatory release. 

Therefore, pursuant to Article 11.07, §3(d), this Court will resolve the above~cited issue 

and then enter findings of fact. 

The Clerk of the Court is ORDERED NOT to transmit at this time any documents in the 

above-styled case to the Court of Criminal Appeals until further order by this Court. 

B:Y the follt>wing signature, the Court ad.opts the 

State;s Propo3ed OrutrDt:Signai.i.ug lssu~. 

SIGNED on the.....:.-- day ot_ flf1 1 8 z.m2 '", __ uv _____ --:----' .ii.J1.i. 

PRE'1 :.~G~GE . ' FILED' 

Chrltl· 02:r.lc! 

District Clerk 

OCT 0 9 20_\Z 

::=~~~{7 r-.,. li ... ll. or" 

...... ,, . 

...... -· ,. 

-,~:~.~ ....... 

.,, . ': .... • ...... I 
>4:. :~ :::--:l ' . Ji' l 'ir 

D Ch r,s :~ () ~ 

~"']) .· '"tr/q <Jniet · 

~-... ~··. . 4/JG .· . Ct?r;c Cause No. 449008-D . . .. < ? 12 <OtJ 

EX PAR~/~~~.;;;0'~~· :.:::> § IN THE 263R0 DISTRICT COURT 

PAUL ALLAN LARSON, 

Applicant 

·-. .... § OF 

§ HARRIS COlJNTY, TEXAS 

STATE'S PROPOSED ORDER DESIGNATING ISSUES 

Having reviewed the applicant's petition for writ of habeas corpus, the Court finds that 

the toliowing issues need to be resolved in the instant proceeding: whether the applicant is being 

illegally denied credit for time spent on supervised release and whether the parole board has 

unlawfully revoked his supervised release. 

Thetefore, pursuant to Article 11.07, §3(d), this Court will resolve the above-cited issue 

and then enter findings of fact. 

The Clerk of the Court is ORDERED NOT to transmit at this time any documents in lhe 

above-styled case to the Court of Criminal Appeals until further order by this Court. 

By the following signature, the Court adopts the 

State's·Proposed Order Designating Issues . 

SIGNED on the ___ day of · . 4{ff6 : 4 'MM~ ..4.111.__;_1\l ___ , 2013-
. ,. 

>· Cause No. 449008~C 

EX PARTE § IN THE 263Rf) DISTRICT COURT 

§- OF 

PAUL ALLAN LARSON, 

Applicant § HARRIS COUNTY, TEXAS 

STATE'S PROPOSED ORDER DESIGNATING ISSUES 

IUtving reviewed the applicant's petition for writ of hab'eas corpus, the Court flnds that 

' 

the following issues need to be resolved in the instant proceeding: whether the applicant is being 

illegally ~Jonfined pursuant to a parole warrant and whether the parole board has unlawfully 

imposed <tJnditions on his mandatory release. 

THerefore, pursuant to Article I I .07, §3(d), this Court will resolve the above-cited issue 

and then anter findings of fact. 

Th~ Clerk of the Court is ORDERED ~ to transmit at this time any documents in the 

above-stylbd case to the Court of Criminal Appeals until further order by this Court. 

By the following signature, the Court adopts the 

State's Proposed Order Designating Issues. 

SIGNED on the_ day of ocr 1 s 2012 . __ ,2012. 

· --- ,rr-Jrr.;r;;T-:.7UU7\Hl.YJ_ .. _______________ ··----------- ----···· ---

Texas Bar I. D. #00787163 
NOTICE: THIS FORM CONTAINS SENSITIVE DATA. 

Cause Number: ~ f; - '2. 0 /o Lf ~ - (The Cle~Toffice will fill in the catse Number when you file this form.) 

Petitioner/ r-} / _ \ 

Plaintiff -fA.uL A-Lt.'AN l,....ri-iSDiJ ----------~~----~~~~~-

In the (check one): 

D liili8t1ict-Court of ~Ml.t-l'f')L iJPPMLS 

(Court Number) 0 County Court at Law 

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 Court Costs" 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. 

D Justice of the Peace 

(County) 

Affidavit of lndigency 

(Request to Not Pay Court Fees) 

You must either 1) sign this form in 

front of a notary public or 2) sign this 

form and sign and attach a completed 

"Unsworn Declaration" form. By 

signing in front of a notary, you swear 

under oath that the information 

provided is true and correct. By 

signing and attaching an "Unsworn 

Declaration" form, you declare under 

penalty of perjury that the information 

provided is true and correct. 

County, Texas 

You can be prosecuted if you lie on 

this form. 

The court may or may not approve this 

request to not pay court fees. The court 

may order you to answer questions 

about your finances at a hearing. At 

that hearing you will have to present 

evidence to the judge of your income 

and expenses to prove that you have no 

ability to pay court fees. 

CD The person who signed this affidavit appeared, in person, before me, the undersigned notary, and stated 

under oath: \ 

"My name is f)-lL$-'b,..j 

"My mailing address is 

"My email address is 

"I am above the age of eighteen (18) years, and I am fully competent to make this affidavit. I am unable to pay court 

costs. The nature and amount of my income, resources, debts, and expenses are described in this form. 

Check ALL boxes that apply and fill in the blanks describing the amounts and sources of your income. 

~ "I receive these public benefits/government entitlements that are based on indigency: 

D SSI D WIC 12(1 Food Stamps/SNAP D TANF D Medicaid D CHIP D AABD 

D Needs-based VA Pension D County Assistance, County Health Care, or General Assistance (GA) 

D LIS in Medicare ("Extra Help") D Community Care via DADS D Low-Income Energy Assistance 

D Emergency Assistance D Child Care Assistance under Child~ Care and Dev~ment Bloc,.k Grant 

D Public Housing ~Other: (Describe) s. s. fJ. /2e:rJR.E:.t'\liltJ r ....-t:ie.AJEF I T.S 

If you receive any of the above public benefits, attach proof and label it "Exhibit: Proof of Public Benefits" 

® "My income sources are stated below. (Check all that apply) 

D Unemployed since: (date) 

D Wages: I work as a 

--------------------------------- -orfor 

Your job title Your employer 

D Child/spousal support D My spouse's income or income from another member of my household (if available) 

D Tips, bonuses.[:JMilitary: t-lq~sing .. D yvorker's Comp D Disability D Unemployment ~ocial Security 

D Retirem~rlt!Pensioii ~ .[)i~i_?~rids: intere~t. royalties D 2"d job or other income: --------~;---";;--;--------

.. ® "My.inC<brrie arrto.ur:l~S~~ai"i~ .~!~tecf 6~19w::~' . (describe) 

. ''(~);My:~fnoritllly:n-~1"i~;td~·g,~(t~;~t~}~;;·af~;·;~~en out is: Total income after taxes~ $ l3til ~ 

(b) The a~d~i{pf ·~e~~~v~:;·~~~h ~o-~t-h 'j~-~~b·i;~ benefits is: Total amount received~ + $ ·.I~ ~ ' :(c) The.~mbun(6f,jQ¢9r;li~;f~Oiii.:ot.h~'~··aeopf~'Jn my household is:* Total amount received ~ + "'$ __ ____.~=--

(d) The '~inoJnt'l fe~~i~~'+e~th~~b~·ffi· f~8h~\).ther sources is: Total amount received ~ + '=$ __ -J*'d'~=-= (e) tVi'tr6{A.~c;;·~?!Jthiy'iQcbrri~·[§ '" .,., . .-:;· Addallsourcesofincomeabove~ = $ 132.~~ *List this inr;:ome only ilother members contribute to your household income. 

Page 1 of 2 

© TexaslawHelp.org- Affidavit of lndigency, February 2014 
I-·,, 

® About my dependents: "The people who depend on me financially are listed below: 

~ry A~ 

1 /~b we.. 

Relationship to Me 

2 

3 

4 -----------------------------------------------------------------------------

5 -----------------------------------------------------------------------------

6 --------------------------------------------------------------------------

® "My property includes: Value* 

Cash $ 4 $ e:>_9 

Bank accounts, other financial assets (List) 

{}.. H-i>cs Fv ~ ~ $ ~ 

$ 

$ 

Vehicles (cars, boats) (List make and year) 

$ 

$ 

$ 

Real estate (house or land) (Do not list the house you live in.) 

$ 

$ 

Other property (like jewelry, stocks, etc.) (Describe) 

$ 

$ 

CV"My monthly expenses are: 

Rent/house payments/maintenance 

Food and household supplies 

. Utilities and telephone 

Clothing and laundry 

Medical and dental expenses 

Insurance (life, health, auto, etc) 

School and child care 

Vehicle payments 

Gas, bus fare, auto repair 

Child I spousal support 

Wages withheld by court order 

Debt payments 

Other expenses (Describe) 

Amount 

$ ~D~ lfrlO · 

$ 'ZL>ote /MD 

$ 'I z.. ~ pYle) • 

$ z_$~ frtO 

$ ~e~ 

$ 

$ 

$ 

$ S?J~fntJ· 

$ 

$ 

$ ~~ 

$ 

$ 

$ 

$ 

Total value of property ~ I= $ l \ D C3'- Total monthly Expenses ~ Ll =___,$ ________ _ *The value is the amount the item would sell for less the amount you still owe on it (if anything). 

® "My debts include: List debt and amount owed. ~~il ~$ 3cD ~ /tvlo ~ 

To list any other facts you want the court to know, such as unusual medical expenses, family emergencies, etc., attach another 

page to this form and label it "Exhibit: Additional Supporting Facts." Check here if you attach another page. 0 

® "I am unable to pay court costs. I verify that the statements made in this affidavit are true and correct." 

®Your Signature. You must either: 1) sign this form in front of a notary public or 

2) si is for 

~ 

and sign and attach a completed "Unsworn Declaration" form. 

6~~~~~~~ Date 

Notary fills out this section !! ~ou-. =- _ ·:.. ___ . _ -, 

are signing in front of a notary!! ,,,~~~~~~z,,, tt! li'\~'V: '"r.l"!:l'-"~~~N · 

I ~o~~·· ··.<l-'~ o a!"Y, stern~ nere: §"( ';'<'§ mary PubliC, State of Texa 

J ';~·r%·~$-~:: My C~ommisst.J'or Expires ~ ... /f' Of\<i-,,~ No" t: r 20 I_---.::.,!!"''::__ - : J~ 1h.: ' ' ' 16 I 

'by ~ -=---·"'"'---=-c..--.··-

Pri t name of person who is signing this Affidavit. 

NOT the notary's name. 

State ofT exas ~ .) f) ' <' 

County of {;c,(C.........'f-......\.-:> . Print the name of county where this Affidavit is notarized. 

~~~~ 

Sworn to a~ed before me today, ;;?-.-..I.._S-(5 

Date 

N~~::> 

Page 2 of2 

© TexaslawHelp.org- Affidavit of lndigency, February 2014 
BNC#: 14Blll5D44177 

/-·------.-.. :--·--·-

SOCl-\L SECTJRlTY ADMINlSTRA TION 

GREATLAKES PROGRAM SERVICE CENTER . 

POBOX 8Cl8 

CHICAGO 1L 6068.0-8018 

OFFICIAL BUSINESS 

P~NALTY FOR PRIWITE USE. $300 

R 

-

Op~n a my Social Security account 

ScciaiSecurity.gov 

P AllL A LARSON 

PO BOX 524001 

HOUSTON TX 77052~4001 

Over..,. 

.. ·.-----~-------4 

~-------------~ FIRST-CLASS MAIL 

PRESORTED 

POSTAGE AND FEES PAID 

SOCIAL SECURITY 

ADMINISTRATION 

PERMIT NO. G·11 

ut1 iuiiii'IIIIIUitl•llultJJIIIhiJ( nhsiiiJII•i•IJu ,,hUI s 

UFTTO OPEN 

' 
.. 

·' 

Your New Ben.efi.i Amou:nt 86E9657 

. /OtJCJS$~ IS"/~ 

BENEFICIARY'S NA.MK PAUL A LARSON 

'rbur Social Security benefits will increase by l. 7 perct;,nt in 20 15 becm ~se of a rise in the cost of 

living. You c~m. m;~ this ictt~:r wh~n you nceri proof of youl' h-cntHt tunouni: to receive t'ood, 

rent:, or eiM~rgy a~f.sistanr:r.; t::1tnk loans; or ib;" other bui~il!cs~. Keep this letter with your 

impmtant financial records . 

.Ho~_l\iln..:.h ·wm.I_Get AD C. \\'het!7.. 

• Your monthly amount (befon:! deductwns) is 

• The amount we deduct for Med.lcare medical insuran~c is - -- (Ifyo1.idid.ricifliave}ifedicafe-as ofNov. 20,2014, 

or if ~x~:Ii\;';(j!J.(~ c·l.[c ~·:tys your premium, we show $(1.00.) 

• The amount 'Ne deduct for your Medicare pr~scription drug plan is 

(If you did not elect withholding as ofNov. 1~ 2014, we show $0.00.) 

• The amount we deduct for voluntary Federal tax withholding is 

(lf you did not elect voluntary tax withholding as of 

Nov. 20,2014, we show $0.00.) 

" After we take any other deductions~ you will receive 

on or about Jan. 2, 2015. 

$0.00. 

$0.00. 

$1,309.00 

lfyou disagree with any of these amounts~ you must write to us within 60 days trom the date 

you receive this letter. \Ve would be happy to review the amounts. 

You may receive your benefits through direct deposit, a Direct Express® can~ or an Electronic 

Transfer Account. If you still receiv~ a paper check and want to switch to an electronic 

payment, please visit the Department of the Treasury~ Go Direct website at www.godirect.org . 

. What lf I Have Questions'? 

Please vi..r.;it our website at www.sociulsecurity.gov tor more information and a variety of online 

serviC{$. You also can calll-800-772-1213 and speak to a representative from 7 a.m. unti17 p.m., 

Monday through Friday. Recorded information and services are available :24 hours a day. Our lines are 

bu.-.iest early in the week, early· in tht: month, as well ~~s during the week between Christmas and New -- ··· 

Year's Day; it is best to call at other times. If you are deaf or hard of hearing~ call our TrY number, 

1-8()0..325-0778.lfyou are out<;;ide the lJnited States, you can oontact any US. embassy or con.sulate 

office .. Please have your Scx~iai Security claim number available when you call or visit al'ld include it on 

any letter you send to Social Security. If you are inside the United States and need assistance of any kind, 

you can visit your local office. 

89&9 LAKES AT 610 DR 

HOVSTON TX 
. . 

., . ~ 

SOCIAL SECURiTY ADMINiSTRATION 

C:~REAT LAKES PROGRAM SERVICE C.E:l\:TER 

600 WEST MADISON ST 

CHICAGO IL 60661·2474 

OFFICiAL BUSINESS 

PENALTY FOA·PRiVATE USc, $.300 

PAUL A LARSON 

c 

M05 

1 

PO BOX 524.00 l 

HOUSTON 'l'X 77052-4001 

u!IUI II lie !r lllulh '''hI! 11111111 h ul ,, hll'•ai!•IIJ 11 !

11 111 

II ·.• 

I!J 

Open a my Social Security account 

. Snr.ialS.ecuribJ . .aoy ___________________ ~---------

HAST..CLASS MAIL 

PRESORTED 

POSTAGE AND FEES PAID 

SOCIAL SECURITY 

ADMINIST~ATION 

PERMIT NO.Q .. f1 

FORM SSA-1099- SOCIAL SECURITY BENEFIT STATEMENT 

' -~ l 2014 • PART OF YOUR SOCIAL SECURiTY BENEFiTS SHOWN IN BOX 5 MAY BE TAXABLE iNCOME. ! 

! • sEE THE REVERSE FOR MORE INFORMATION. 1 e 

~x 1. Name i6ox 2. Benefic:ary's Social Security Numbe~J§ 

\ PAUL A LARSON I . 386-40-3920 i! 

1---- I E 

j Box 3. Benefits Paid in 2014 ! Bo~ 4. 8el1efliSRep-aldto ssAir, 201-4- Boxs: N~t~$ncf.lts 9[.?'0:1~:(BC>K.~:'ilif1us~"'4) ::: 

$16.620.00 i $700.00 . __ _ _ _. $t5;~#0.QO. ·_ ~ 

~-------- oEscRIPTtoN oF AMouNTfN eox 3 ·--r--·--- oescRtPrt~N ~~AMouNT rN aox d 

! Paid by check or direct deposit $15.920.00 I Deductions for work or other 

Deductions for work or other adjustments 

~-tdjustnlfmts $700.00 i Benefit.-; repaid to SSA in 2014 

Total Additions flil6.620.0tl 1 

i Benefits for 2014 $113 6')0 00 · 

I '" I 

L ____ _ I 

1

\1 Box •3. Vo;untary Federal Income Tax Withheld 

NONE I r-·-----·------

1 Box 7. Address 

I 

I 

I }'AULA LAltSOl'~ 

PO BOX 524001 

HOUSTON TX 77052-4001 

$700.00 1 

$7Q0.QQ I 

I 

I 

I 

i 

~ 

I 

~ I 

! 

I 

I 

I 

I I 

h I~ 

8-;;;~~ C:iai~• Number (t.Jse :."'is number if yov need to contact SSA) ~ -

I 1.:. 

i 1 386-40-3~}20A ·_j'~ I . ~------------- ~ F SSA. · 099 SM (·,··:; 15 !~--·--~------,- 00 ij(;fili'i'iJR~VHis'F-oRMTO s~ 0~ lAS, . . . .. ---~·-.•. orm -l • ''- . . ,. . . . . ......... .