COURT OF APPEALS FOR THE

FIRST DISTRICT OF TEXAS AT HOUSTON

ORDER

Appellate case name: Maribel Woodard v. McDonald’s Corporation HK 

Management, Inc d/b/a McDonald/037097 and Manager, 

McDonalds Restaurant #307097

Appellate case number: 01-17-00204-CV

Trial court case number: 2013-58383

Trial court: 269th District Court of Harris County

The Clerk of this Court’s March 24, 2017 notice to the district clerk requested an 

indigent clerk’s record by April 28, 2017, after appellant had filed a “Statement of 

Inability to Afford Payment of Court Costs or an Appeal Bond” (“Statement”), which is 

a new affidavit of indigence form approved by the Texas Supreme Court. This 

Statement was filed by appellant, Maribel Woodard, in both this Court and the district 

court on March 13, 2017. Instead, on April 18, 2017, the district clerk filed an 

information sheet in this Court stating that the clerk’s record will not be filed because the 

appellant has not made payment arrangements.

Rule 20.1 provides that a party who files such a Statement in the trial court will

not have to pay costs in the appellate court unless the trial court overruled the party’s

claim of indigence in an order that complies with Texas Rule of Civil Procedure 

145. See TEX. R. APP. P. 20.1(b)(1) (amended; eff. Sept. 1, 2016). However, the Court

is unable to determine whether a contest was filed or if the trial court overruled this

claim of indigence in such an order. See id.

Accordingly, the Court ORDERS the d is tri ct clerk to file a supplemental

clerk’s record containing the attached appellant’s “Statement of Inability to Afford 

Payment of Court Costs or an Appeal Bond in Justice Court,” any contests filed, and any

order granting or overruling appellant’s indigence claim. The supplemental clerk’s

record on indigence shall be filed in this Court within 20 days of the date of this order.

It is so ORDERED.

Judge’s signature: /s/ Laura Carter Higley

 Acting individually 

Date: May 4, 2017
NOTICE: THIS DOCUMENT CONTAINS SENSITIVE DATA

In the (Ch(,d,. one}: ••••••

..~?~.!.~- g~~~~!~~I County Court at Law

o Justice Court

-.liill.rriS Texas

CO(!I!(Y

McDonald1rtorporation

Defendant,,",K Management, l~~ __.__

(Print first ami last nemo of !t1i!/ (XJrocn bf:JIIl[J suea.}

Statement of Inability to Afford Payment of

Court Costs or an Appeal Bond

1. Your Information

My full legal name is: Maribel Nadina Wooda~~_~~__ My date of birth is: ~ f 201 1947

First .- /Alddf"l Last MOmlVD,,},;;;;;;;;

My address is; rHomfJ) 5329 Carmen Houston, TX 77033-3205

(Maifing) Same as Above ,~~~---------------- My phone numberS32-654-1093My email: MaribeIWoodard6@9mail.com

About my dependents! "The people who depend on me financially are listed below.

Name

2

3

4 _

5 _

6 -

------_.-._---- --_._ ...

---- ---~-.-..-

----_ ..__ _.__ .-

------ ----_.-.... ---.. ----------

2. Are you represented by legal Aid?

o I am being represented in this case for free by an attorney who works for a legal aid provider or who

received my case through a legal aid provider. I have attached the certificate the legal aid provider

gave me as 'Exhibit: Legal Aid Certificate.

-orO I asked a legal-aid provider to represent me, and the provider determined that I am financially eligible

for representation, but the provider could not take my case. I have attached documentation from

legal aid stating this.

ortxJ I am not represented by legal ald. I did not apply for representation by legal aid.

3. Do you receive public benefits?

o I do not receive needs-based public benefits. - or •

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

rCheck ALL boxes thal apply and iilriiileiJ proof /0 tillS form. such as d ur (,heck)

\iI Food stamps/SNAP TANF !,...-, Medicaid CHIP S51 WIC [] MBD

o Public Housing or Section B Housing Low-Income Energy Assistance Emergen.cy Assistanc_e

o Telephone Lifeline Communi Care via DADS 0 US in Medicare ("Extra Help")

o Needs-based VA Pension Child Care Assistance under Child Care and Development Block Grant

[J County Assistance, County Health Care, or General Assistance (GA)

o Other:

C Form Approved by the Supreme Court ofTexas by order in Misc. Docket No, HHJ122

Statement of Inebility to Afford Payment ()f Coun Coots

Page 1 012

ACCEPTED

2013-58383

FIRST COURT OF APPEALS

HOUSTON, TEXAS

3/13/2017 11:51:42 PM

CHRISTOPHER PRINE

CLERK

 FILED IN 1st COURT OF APPEALS HOUSTON, TEXAS 3/13/2017 11:51:42 PM CHRISTOPHER A. PRINE Clerk ------------------------ VOID CM ------------------------ RECEIVED IN 1st COURT OF APPEALS HOUSTON, TEXAS 3/13/2017 11:51:42 PM CHRISTOPHER A. PRINE Clerk
4. What is your monthly income and income sources?

"I get this monthly income:

$_Sl...6.JlQin monthly wages. I work as a Home Health Providerfor .f.:3eacon Home Health Agency

~t~i)tlr/ot'~f}i!e-'--'--' w ";':;:::,;";:t 0f!'~pI0'/er ~---

$ in monthly unemployment. I have been unemployed since

$ 335.94 in public benefits per month.

S from other people in my household each month; (List on!v if otfu;;! memb&/s cortniJut()

househaid iflCoroo.)

$ 830.00 from 0 RetiremenUPension Tips, bonuses 0 Disability WOrker's Camp

~ Social Security Military Housing D Dividends. Interest, royalties

LJ Child/spousal support

[J My spouse's income or income from another member Of my household (If 8Vdii<JUe)

$ 545.67 from other jobs/sources of income. Disability Insurance - car payment

$2,287.6115 my totai monthly income.

5. What is the value of your property?

"My property includes: Value·

Cash .$ _

Bank accounts, other financial assets

Savin~ .. $ 10.00

_t...,.

.-$-~--- ...

VehiCles (cars, boats)

--201.1. Ford Esccspe-- _1610.00

________ .,_~ .."., "..__ .. Ji. _,.._.._.. _

$

Other property (like jewelry, stocks, land.

another house, etc.)

-$---

.1__ "._.

s

Total value of property,·$'620.00

'iall16 is SId fu;"IBss the

----------_ ..._ ..•.,.•••......

6. What are your monthly expenses?

"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

Transportation, auto repair, gas

Child! spousal support

Wages withheld by court order

Amount

$ 750.00

i500.00·

$422.12

$"200.00

'$-'50.00 ...

_~2S91_0.1_

s

i200.00

s

Debt payments paid to;

See Attached

Total Monthly Expenses

on

7. Are there debts or other facts explaining your financial situation?

"My debts include: (Lmt debt <111(1 amount o'l<<edl . , ~ _.." .

This does ..not tcskein ..aCCQUntanyunexpec:tedemergencJes .•

8. Declaration

I declare under penalty of perl!Jry that the foregoing is true and correct I further swear:

)(d. '-1 I cannot afford to pa.... y court costs.

'XlI cannot furnish an ap al.bon or

Mynameis-LLL~~~~~~~~LM~~~--~r---~

MyaddM6S$ __ ~~~L-~-£~~~~~ __ ~~~LL~~~a=~L-~~~~--,~~~

~~

@FormApproved by tM Supreme Court of Texas by order in Misc. Docket No 16-9122

Statement of Inability to Afford Payml')nt of Court Costs Page 2 of2