NOTICE: THIS DOCUMENT CONTAINS SENSITIVE DATA Cause Number: (The Clerk's office will fill in the Cause Number when you file this form) Plaintiff: (Print first and last name of the person filing the lawsuit.) In the And Court Number (check one): Defendant: (Print first and last name of the person being sued.) County District Court County Court / County Court at Law Justice Court Texas Statement of Inability to Afford Payment of Court Costs or an Appeal Bond 1. Your Information My full legal name is: First Middle Last My date of birth is: / / Month/Day/Year My address is: (Home) (Mailing) ___________________________________________________________________________________ My phone number: Name My email: Age Relationship to Me About my dependents: "The people who depend on me financially are listed below. 1 2 3 4 5 6 2. Are you represented by Legal Aid? 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. -orI 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. orI am not represented by legal aid. I did not apply for representation by legal aid. 3. Do you receive public benefits? I do not receive needs-based public benefits. - or I receive these public benefits/government entitlements that are based on indigency: (Check ALL boxes that apply and attach proof to this form, such as a copy of an eligibility form or check.) Food stamps/SNAP TANF Medicaid CHIP SSI WIC AABD Public Housing or Section 8 Housing Low-Income Energy Assistance Emergency Assistance Telephone Lifeline Community Care via DADS LIS in Medicare ("Extra Help") Needs-based VA Pension Child Care Assistance under Child Care and Development Block Grant County Assistance, County Health Care, or General Assistance (GA) Other: � Form Approved by the Supreme Court of Texas by order in Misc. Docket No. 16-9122 Statement of Inability to Afford Payment of Court Costs Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 4. What is your monthly income and income sources? "I get this monthly income: $ in monthly wages. I work as a Your job title for Your employer . . $ $ $ $ in monthly unemployment. I have been unemployed since (date) in public benefits per month. from other people in my household each month: (List only if other members contribute to your household income.) from $ $ Retirement/Pension Tips, bonuses Disability Worker's Comp Social Security Military Housing Dividends, interest, royalties Child/spousal support My spouse's income or income from another member of my household (If available) from other jobs/sources of income. (Describe) is my total monthly income. 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 Debt payments paid to: (List) 5. What is the value of your property? "My property includes: Value* Cash $ Bank accounts, other financial assets $ $ $ Amount $ $ $ $ $ $ $ $ $ $ $ $ $ Vehicles (cars, boats) (make and year) $ $ $ Other property (like jewelry, stocks, land, another house, etc.) $ $ $ Total value of property $ Total Monthly Expenses $ *The value is the amount the item would sell for less the amount you still owe on it, if anything. 7. Are there debts or other facts explaining your financial situation? "My debts include: (List debt and amount owed) " (If you want the court to consider other facts, such as unusual medical expenses, family emergencies, etc., attach another page to this form labeled "Exhibit: Additional Supporting Facts.") Check here if you attach another page. 8. Declaration I declare under penalty of perjury that the foregoing is true and correct. I further swear: I cannot afford to pay court costs. I cannot furnish an appeal bond or pay a cash deposit to appeal a justice court decision. My name is My address is Street City State Zip Code Country State . My date of birth is : / / . signed on Signature / / in county name County, Month/Day/Year � Form Approved by the Supreme Court of Texas by order in Misc. Docket No. 16-9122 Statement of Inability to Afford Payment of Court Costs Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com