Court Opinion

ID: 4065252
Source: CourtListenerOpinion
Date Created: 2016-09-29 21:55:05.431919+00
Date Added: 2024-06-11T14:05:55.574739
License: Public Domain

AFFIDAVIT OF INDIGENCE

                             CAUSE NO. ____________________

                                IN THE COURT OF CRIMINAL
                                    APPEALS OF TEXAS

THE STATE OF TEXAS:
COUNTY OF AUSTIN:

         The undersigned makes this affidavit in connection with the filing of the above-numbered
and entitled cause without the posting of a security deposit and for the purpose of having citation
issued in accordance with Texas Rule of Civil Procedure 145 and Texas Rule of Appellate
Procedure 20.1. (The items applicable to the undersigned and checked and the information called
for is furnished under penalties of perjury.)

1. Basis for indigence: I am unable to pay a court cost because:

       I am presently receiving a government entitlement based on indigence as follows
       (describe nature and amount of government entitlement):

       Supplemental Nutrition Assistance Program (SNAP) benefits at $194 per month until the
       month of October, 2015 and have been approved for assistance under the Workforce
       Investment Act.

and

       I have no ability to pay court costs based on facts set out below.

2. Employment information:

       I am not now employed; the last time I was employed was on March 3, 2015 to March
       19, 2015 at Amazon Fulfillment Center, located at 700 Westport Pkwy, Fort Worth, TX
       76177. Due to medical reason (pulmonay embolism), I was forced to resign from the
       aforementioned employer.

3. Income from sources other than employment:

       I have no income which is derived from employment, as I am currently unemployed, no
       do I have income which is derived such as interest, dividends, annuities, etc.

4. I am single and have no Income from a Spouse.

                                                 1
                                  AFFIDAVIT OF INDIGENCE

5. Property:

       I own no property and no interest in any property.

6. Bank Accounts: (statements attached hereto, and incorporated herein)

               Bank                          Type of Account                       Amount

       MB Financial Bank                     Checking                              $2.33

7. Dependents:
       I have no dependents.

8. Debts:

       I have the following debts:

               Creditor                              Amount

       John Peter Smith Hospital                     $42,920.40

9. I have the no monthly expenses. I am currently living with an immediate family member, i.e.,
sister, who pays added electric and water utilities incurred by my presence and living with her.

10. Attorneys: I am not represented by an attorney in this court nor was I represented by an
attorney in the trial court.

        I, Jason Childress, Affiant herein, am Indigent and unable to pay the costs of court.
Further, I am unable to provide the required 11 copies pursuant to T.R.A.P. Rule 9.3. (b) (1) and
request that requirement be waived. I verify that the statements made in this affidavit are true and
correct..

                                                                            Respectfully submited,

                                                                     /s/: Jason Childress
                                                                                           Affiant,
                                                                                 Jason T. Childress

Signed this the 3rd day of August , 2015.

                                                 2
                                AFFIDAVIT OF INDIGENCE

                                      VERIFICATION

Executed without the United States:

Pursuant to 28 U.S. Code § 1746 (a): I, Jason Truman Childress, Affiant herein, in lieu of
Notarization of this document, due to an inability to pay therefor, do declare, certify, verify
and state under penalty of perjury under the laws of the United States of America that I am a
living man, of lawful age and facts ans statements made herein by me are true and correct.

Executed on this 3rd day of August , 2015.

                                                                 /s/: Jason Childress
                                                                                Jason Childress
                                                                             9141 Gristmill Ct.
                                                                             Fort Worth, Texas

                                              3
                                                                                           Form TF0001
                                                                                              April2015
         TEXAS HEALTH AND HUMAN SERVICES COMMISSION
         P O BOX 149029
         AUSTIN, TEXAS 7 87 1 4.9A29
                                                       l*hTE,\AS
                                                       hfr'*HlllruIffi'll*
          oate:   06115/2015
                                                       Need help?
   GaseNumber: 1025563950
Call 2-1 -1 or 1 -877-541 -7905
                                                       lf you have a hearing or speech disability,
                                                       call 7-1-1 or any relay service.
                                                            All numbers are free to call.

                                                       JASON CHILDRESS
                                                       9141 GRISTMILL CT
                                                       FORT WORTH TX 76179.5007

Notice about your case:
SNAP Food Benefite
EDG numtrer:632939553

                               Who gets SNAP Food Benefits
                      Name                                Date                       Monthlv Amount
Jason Childress                                  47to1t2015 - 10t31na15                 $ 194.00

                                         Page 1 of2                                                   ,937
                                                                    Save

                               JPS Health   Network

                 Eligibility and Enrollment Department

This patient has been approved for JPS Connection plan:         JPS connection   rier   1 Approved

Name:  JASON              CHILDRESS Participant #:

Additional Family Members.

Address:   9141 GRISTMILL CT
           FORT WORTH TX 76179

Start Date: A4n512CI15                      Expiration Date:   0412512016

Eligibility Screenen   Jutie

                                                                             Save
                                                          JPS    Connection Program Copay
                                                               Effective November t, 2014

iqlt            tlriii$.iiiiirti                                                                            t.,   ii   :.:::r:ll,-:::::.,1r!-

                                                                                                        JPSC Supplemental
                            fcrttrri:ij iir fririr                 Homeless           JPSC
   nsi                      Powered by Pride
                                                                     Copay            Copay
                                                                                                       to Medicare/lnsurance
                                                                                                                       Copay

Outpatient Visit
                                                                        SO                Ss                               Ss
Primarv /Soecialtv Care
Urgent Care                                                             $o            5zs                                52s
Emerqency Room Visit[x                                    J)            SO            $zso                             Szso
  ii,ri.: irii:;irj:*+;i.
                                                                        So         $200 Maximum            $200 Maximum
lnpatient Hospitalizat,on J$s,
                                                                   $0 ea add day   5100   ea add day       SlOO ea add day
ii::i::ir+;t-:i!.,?,,.?1,

Colonoscopy and
Mammogram                                                               $0                $0                                $0
(Preventive/Screen i no)

Physical Therapy                                                                           $5                                $5
                                                                        $0
                                                                                      Per Visit                        Per Visit

Radiation Therapy                                                                         $ro                              $ro
                                                                        SO
Chemotherapy                                                                          Per Visit                        Per Visit

Lab/Radiology
Other Testingff reatments                                               So                So                                So
Level l& ll

Lab/Radiology Level lll,
Diagnostic Golonoscopy                                                  SO                Sso                             Sso
Diagnostic Mammography
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Outpatient Surgery
Cardiac Cath, Angio, l/R
                                                                        SO                Slso                           Srso

                                                                                                          According to Plan
 Diabetic Supplies                                                      $0                s10
                                                                                                             Documents
 Prescription Drugs Tier                             I
                                                                                                          According to Plan
 generic (Limit 5, 30 day                                               SO                 $5
                                                                                                             Documents
 supply)
 Prescription Drugs Tier ll
                                                                                                          According to Plan
 non- generic (Limit 5, 30 day                                          $o                $10
                                                                                                             Documents
 suoolv)
 Prescription Drugs Tier lll                                                                              According to Plan
 (Limit 5. 30 dav suoolv)                                               SO                $20
                                                                                                             Documents

                                fu,w*t'1fr',J
 Executive Director, Revenue
 Cycle

 Revised 10130/14
                                                                                   a#*q
                                                                                                        PO Box 916046          r   Fort Worth TX 76191
                                                                                                                     Telephone: (&M) 2194565

Thank you for choosing JPS Health Network. We hope to continue serving your healthcare needs. All insurance
carriers were billed and have processed your claim" The outstanding balance is now due. lf you have any
questions or concerns about your bill, please contact our Customer Service Department at (844) 21 94565
between the hours of 8:00 am to 5:00 pm.

Thank you in advance for your cooperation and prompt attention to this matter. We look forward to serving you
and your family in the future.

                                                                   STATEMENT                         Por{e          o -tl;-t I JC,'.                   _

Summary
Guarantor Name                                      CHILDRESS, JASON                  FOR BILLING QUESTIONS: Please call
Statement Date                                              07t17t2015
Account Number                                           06000{989379                        JPS Health Network
Total Patient Responsibility                                                                 Business Office
                                                                    42,920.40
                                                                                             Toll Free: (844) 2194565
Payments                                                                 0.00                Monday     -   Friday 8:00 am to 5:00 pm

                                                                                      INSURANCE INFORMATION
                                                                                      Company Name: SELF PAY
                                                                                      Policy Holder: CHILDRESS,JASON
                                                                                      Policy Number:
                                                                                      For your privacy, a portion of the policy number has been
                                                                                      hidden. Please contad us with any changes or corrections.
                 Nature is important ,.. So is convenience!
                    To make a payment, update your
                    information, and more, visit:
                     wunr.med billoffice.com/ipshn                                                                                        $0.00
                     use Record Locator#: 3fi16550

                 Space only permits for a limited number of accounfs. P/ease call our office with any billing questions.

                                       PLEASE SEE REVERSE SIDE FOR IMPORTANT INFORMATION
                                                                                                                                   808CSFPRS03241 000000227
                                          "**Please Detach Lower Portion and Return With Payment***

                                                                                                             To make payment online, go to
                                                                                                             www.medbil loffice.com/jpshn and
JPS Health Network Business Office                                                                           use Record Locator # 3436550
PO Box 1660
Greeley CO 80632-1660
ADDRESS SERVICE REQUESTED

                                                                                SEND ALL PAYMENTS TO:
 July 17,2015
                                                                                JPS Health Network
                                                                                Business Office
3436550-2410000227 638460225                                                    PO Box 916046
l;lllllrrrlrlrrrllll'lllrrtllt'rr1'llrtlltltll,tt,illlrlu,ltrtll                Fort Worth TX 76191-6046
Jason Childress                                                                 11,,,1,11,,,,'lll'1,',,,11,11,,11,,,,1,,1,11,',l,,l,ll,,ll,,,l
9141 GristmillCt
Fort Worth TX 76179-5007