### 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 ofthe 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 ofperjurythat 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. CheckALL boxes that apply and fill in the blanks describing the amounts andsources ofyourincome. 

### ® "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 Ifyou receive any ofthe above public benefits, attach proof and label it "Exhibit: ProofofPublic 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 (ifavailable} 

## 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 aftertaxes 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 Addall sources ofincome above-+ *List this income only ifothermembers contribute to your household income. © TexaslawHelp.org- Affidavit oflndigency, 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 andyear) $ $
$ 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 unusualmedical expenses, family emergencies, etc., attach another page to this form and label it "Exhibit: Additional Supporting Facts." Check here ifyou attach anotherpage.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 ofa notarypublic or 2) si is for ,andsign and attach a completed "Unsworn Declaration" form. I

## ~ Date 

### State ofTexas

# 1-tC. ."> D 

# 'S County of 

## U(<......**~** 

## \.;

. Print the name ofcounty where this Affidavitis 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 oflndigency, 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 

## ofAugust, 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 offact. The Clerk ofthe Court is ORDERED NOT to transmit at this time any documents in the above-styled case to the Court ofCriminal 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 onthe.....:.-- day 

## ot_ 

# flf1 

# 18z.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:.

### :~ 

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' 

# . Ji' l 'ir Ch

## :~**~"'])** D 

### 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 offact. The Clerk ofthe Court 

### is ORDERED NOT to transmit 

### at this time 

### any documents in lhe above-styled case to the Court ofCriminal 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 ORDERDESIGNATING ISSUES IUtving reviewed the applicant's petition for writ ofhab'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 offact.**Th~** 

### Clerk ofthe Court is ORDERED**~** 

### to transmit at this time any documents in the above-stylbd case to the Court ofCriminal 

### Appeals until further order by

### this Court.



### By

### the following signature, the Court adopts the 

### State's Proposed OrderDesignating Issues.

SIGNED 

### on the_day of 

# ocr 1

# s2012

. __ ,2012.

· --- ,rr-Jrr.;r;;T-:.7UU7\Hl.YJ_

.._______________ ··----------- ----···· --- 

### Texas Bar I.

### D. #00787163NOTICE: 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 ofperjurythat 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. CheckALL boxes that 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: 

### 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 Ifyou receive any ofthe above public benefits, attach proof and label it "Exhibit: ProofofPublic Benefits" 

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

## D Unemployed since: (date) 

### D Wages: I work as a --------------------------------- -orfor Yourjob title Your employer 

### D Child/spousal support 

### D My spouse's income or income from another member of my household (ifavailable) 

### 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 oflndigency, February 2014I-·,,



### ® 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 andyear) $ $
$ 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 \

## DC3'- 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 ifyou attach anotherpage.

### 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 ofa notarypublic 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 ofa 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 ofperson who is signing this Affidavit. NOT the notary's name. State ofT exas

## ~ .) f) ' <' County of 

### {;c,(C.........'f-......\.-:>

. Print the name ofcounty where this Affidavitis notarized. Sworn to

## a~ed before me today, 

# ;;?-.-..I.._S-(5**~~~~** Date

# N~~::>

Page 2 of2 © TexaslawHelp.org- Affidavit oflndigency, February 2014

## BNC#: 14Blll5D44177
/-·------.-

..:--·--·-

SOCl-\L SECTJRlTY 

### ADMINlSTRATION 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 PAllL 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,,hUIs

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.7perct;,nt in 20 15 becm**~se** 

### ofarise in the cost of living. You**c~m. m;~**  

### this**ictt~:r wh~n**  

### you nceri proofofyoul' 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_GetADC. 

### \\'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 (lfyou 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 ofthese**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 yourbenefits through direct deposit, a Direct Express®**can~** 

### or an Electronic Transfer Account. 

### Ifyou still**receiv~** 

### a paper check and want to switch to an electronic payment, please visit the Department ofthe**Treasury~** 

### Go Direct website at 

## www.godirect.org

.

. What 

## lfI Have Questions'? 

### Please vi..r.;it ourwebsite at 

## www.sociulsecurity.gov tormore information and avariety ofonline serviC{$.

### You also can calll-800-772-1213 

### and speakto arepresentative from 7 a.m. unti17 p.m., Monday throughFriday. Recordedinformation and servicesare available :24 hours a

## day. Our

### lines are bu.-.iest earlyin the week, 

### early· in 

### tht: month, 

## as well**~~s** 

### during the weekbetween

### Christmas 

### andNew

-- ··· Year's Day; it 

### is bestto call at othertimes. Ifyou are deaforhard of**hearing~** 

### call ourTrY number, 1-8()0..325-0778.lfyou 

### are out<;;ide 

### the lJnited States, you can oontact 

## any US. embassy 

### orcon.sulate office

.. Please have your**Scx~iai** 

### Security 

### claim number available when you call orvisit al'ld 

### include it

### on 

## any letter

## you sendto Social Security. Ifyou are inside the United States and need assistance ofany kind, you can visityourlocal 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

## !rlllulh

## '''hI!111111 11 

## h

ul,,

## hll'•ai!•IIJ 11 

## !11 111 

# II ·.• I!J 

### Open a my Social Securityaccount

. 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. 1e

### ~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 SSAin 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 ifyov 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 • ''-

. . ,. . . . . ......... .