CAUSE NO. ____________________ _____________________ * IN THE DISTRICT COURT VS. * _____ JUDICIAL DISTRICT _____________________ * IN COUNTY COURT AT LAW _____ OF NUECES COUNTY, TEXAS AFFIDAVIT OF INDIGENCY (RULE 145, T.R.C.P.) 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 Rule 145, T.R.C.P. (The items applicable to the undersigned are checked, and the information called for is furnished under penalties of perjury.) 1. Basis for indigency: I am unable to pay a court cost deposit because: () I am presently receiving a government entitlement based on indigency, to wit: (Describe nature and amount of government entitlement). _______________________________________________________ _______________________________________________________ _______________________________________________________ () 2. I have no ability to pay court costs based on facts set out below. Employment Information: () I am not employed; the last time I was employed was ______________________________________________________ () I am employed; I work for _______________________________________________________ The nature of my job is ___________________________________ The income I receive from this job is $___________ per ________. American LegalNet, Inc. www.USCourtForms.com 2 3. Income from sources othe r than employment: ( ) I have no income which is derived from sources other than employment, such as interest, dividends, annuities, etc. ( ) I have income derived from sources other than employment as follows: Type of income: ______________ ______________ ______________ 4. Amount per period: ________________ ________________ ________________ Spouse’s income: ( ) My spouse has no income. ( ) My spouse has income as follows: Type of income: _____________ _____________ _____________ 5. Amount per period: ________________ ________________ ________________ Property: ( ) I own no property and no interest in any property. ( ) I own the following interests in property: Real estate ______________________________________________ ________________________________________________________ Motor vehicles ___________________________________________ ________________________________________________________ Stocks and/or bonds _______________________________________ ________________________________________________________ Other __________________________________________________ ________________________________________________________ Cash ___________________________________________________ ________________________________________________________ American LegalNet, Inc. www.USCourtForms.com 3 6. Bank Accounts: Bank _______________ _______________ _______________ 7. Type of Account ________________ ________________ ________________ Amount _________ _________ _________ Dependents: ( ) I have no dependents. ( ) I have the following dependents: Name and age: _____________________ _____________________ _____________________ _____________________ _____________________ 8. 9. Relationship: _________________ _________________ _________________ _________________ _________________ Debts: ( ) I have no debts. ( ) I have the following debts: Creditor: _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ Amount: ________________ ________________ ________________ ________________ ________________ ________________ Expenses: I have the following monthly expenses: Type of Expense: Amount per month: _______________________ ________________ _______________________ ________________ _______________________ ________________ _______________________ ________________ _______________________ ________________ American LegalNet, Inc. www.USCourtForms.com 4 Signed this ______ day of _______________, 20____. I am unable to pay the court costs. I verify that the statement made in this affidavit are true and correct. ______________________________ AFFIANT Sworn and subscribed before me this _______ day of __________________ 20_____. ____________________________________ Notary Public in and for the State of Texas My commission expires ________________ American LegalNet, Inc. www.USCourtForms.com