Case No: ____________________ (Print court information, exactly as it appears on your Petition) In the (check one): District County Justice Court of: _______________________ County, Texas Affidavit of Inability to Pay Costs State of TexasCounty of ______________________________________ (Print the name of county where this statement is notarized) The person who signed this affidavit appeared, in person, before me, the undersigned notary, and stated under oath: “My name is __________________________________. I am above the age of eighteen (18) years, and I am fully competent to make this affidavit. The facts stated in this affidavit are within my personal knowledge and are true and correct. My income, resources, and expenses are described below. Monthly Income Describe source of income: Amount Net Employment $ Public Benefits $ Other Income $ * Spouse's Income $ * List your spouse’s income ONLY IF your spouse contributes to your household income. Total Monthly Income $ Number of Dependents (Include yourself and your dependents) Property Year: Year: Make: Cars or Trucks Make: Checking Account Amount $ Savings Account Amount $ Cash Amount $ Bank: Bank: Other Property (Do not list the home where you live) Monthly Expenses Rent/Mortgage $ Food $ Child Care $ Car Payment $ Medical/Dental $ Utilities $ Transportation $ Clothing/Laundry $ Other: $ Insurance $ Total Monthly Expenses $ Texas Affidavit of Inability to Pay Costs, March 2011 Partnership for Legal Access Page 1 of 2 monthly payment: Debts and child support obligations* Who do you make payments to? Creditor Creditor Creditor Creditor Creditor Creditor $ $ $ $ $ $ *Do not include house payments and automobile payment. Total Monthly Debt Payment $ “I am unable to pay court costs. I verify that the statements made in this affidavit are true and correct.” Do not sign until you are in front of a notary. Signature Date Notary fills out below. State of Texas, County of (Print the name of county where this statement is notarized) Sworn to and subscribed before me, the undersigned notary, on this date: By . (Print name of person who is signing this affidavit.): (Notary’s seal here) Notary’s signature Texas Affidavit of Inability to Pay Costs, March 2011 Partnership for Legal Access Page 2 of 2