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NOTICE: THIS FORM CONTAINS SENSITIVE DATA.

Cause Number:

FILED IN COURT OF APPEALS

12th Court of Appeals DfeMct /

The Clerk's office will fill in the Cause Numberwhen you ft J Mis ft irm.)

n the (checkone)

APR-9:2015.

-I

Petitioner/

Plaintiff y^>r\

TYLER TEXAS

^5JrYN ST District cjou£ATHY S. LUSfocjpLEFfcte (Court Number) Q County Court at Law i*i.

£2s<d A. A>

• Justice of the Peace

County, Texas Respondent/

Defendant

*o o

(County)

1*^30><r\S

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.

Affidavit of Indigency

(Request to Not Pay CourtFees)

You must either 1) sign this form in

front of a notary public or 2) sign this

You can be prosecuted if you lie on

this form.

form and sign and attach a completed The court may or may not approve tnis

"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 ofperjury that the information

provided is true and correct.

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

under oath:

"My name is £~Js<^ / A. QxjbmQ , My phone number is (683. )30l-^t?qD- "My mailing address is *?3S ^UJ^k Y>, Are>.C*xjirse. , ^TTM. ^CO^i

"My email address is g_dcWors <^Ci'< (€) c^CTscri i'.. C^sv^

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.

-? "I am above the age of eighteen (18) years, and I am fully competentto make this affidavit. Iam unableto pay court

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

Check ALL boxes that apply andfill inthe blanks describing the amounts andsources ofyourincome.

® "I receive these public benefits/government entitlements thatare basedon indigency:

• SSI DWIC • Food Stamps/SNAP • TANF • Medicaid • CHIP • AABD • Needs-based VA Pension • 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 Careand Development Block Grant

• Public Housing Q Other: (Describe)

Ifyou 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) -orf°r feu/fc^ PloAu-k Re^l-Lf -K'Wages: Iwork as a Z^Wr?,IflA'.^ /ec^-A - Your job title Your employer

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

• Tips, bonuses • Military Housing Q Worker's Comp • Disability • Unemployment • Social Security

• Retirement/Pension [J Dividends, interest, royalties D 2nd job orother income:

© "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:

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

(d) The amount I receive each month from other sources is:

(e) My TOTAL monthly income is Add allsourcesofincome above

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

©TexasLawHelp.org - Affidavit of Indigency, February 2014

(describe)

Total income after taxes ->

Total amount received -*

Total amount received ->

Total amount received -#

$ -&

$ -0-

&

o <3

= o IjiBaE0

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

Name Age

1

2

Relationship to Me

5

6

© "My property includes:

Cash

Bank accounts, other financial assets (List)

$ -&-

$ lS^

jSl

Vehicles (cars, boats) (List make andyear)

i $ -£5-

**S-

$ &-

Real estate (house or land) (Do notlist thehouseyoulive in.)

$ jg£r

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

$ ^^

©"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 / spousal support

Wages withheld by court order

Debt payments

Other expenses (Describe)

Total value ofproperty -* |= $fx3Q-°° Total monthly Expenses

'The value is the amount the item would sell for less the amount you still owe on it (ifanything).

© "My debts include: List debt and amount owed. s*\—

Amount

$ <3os-go

$ ?ko: °o

$ 2ooc0

$ •&

J4&- oQ

-&-

-e-

-e-

-er

$ u-

-e-

-<&

•©-

•G-

=$/)9£f?Q- CO

Tolist any otherfacts you wantthe courtto know, such as unusual medical expenses, family emergencies, etc., attach another

page to thisform and label it "Exhibit: Additional Supporting Facts." Checkhere ifyou attachanotherpage.O

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

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

2) sign this/prm and sigffhpd attach a completed "Unsworn Declaration'' form.

State of Texas

County of "fcyyJUT"

Print the name of county where this Affidavit is notarized.

Sworn to and subscribed before me today, Any}) 7 2f>i % , by &o£&\ f\wi&S 7)\XOH.

\Lf fih7 /] y /^» ' Plato Drirtt rt**ma r\f r\esrt*s\n ttihn le* n!nn;'nA fkiV.

Notary fills out this section ifyou

are signing in front of a notary.

Notary stamp here

Date Printname of person who is signing this Affidavit.

NOT the notary's name.

Notary's Signature

© TexasLawHelp.org - Affidavit of Indigency,

r**- !^TM** ********^**************^^^^

SHILU SHRESTHA

NOTARY PUBLIC

STATE OF TEXAS

MYCOMM.EXR 11/08/17

Page 2 of 2