ACCEPTED
13-14-00716-cv
W \u ^vu cvy THIRTEENTH COURT OF APPEAL
CORPUS CHRISTI, TEXAS
1/13/20159:21:08 PM
DORIAN RAMIREZ
CLERK
NOTICE: THIS FORM CONTAINS SENSITIVE DATA.
Cause Number
(The Clerk's office wW fill inthe Cause Number when youm this form.)
In the (check one}:
Petitioner/
Plaintiff • District Court
{Cou/t Number) fj County Court at Law
D Justice of the Peace
Respondent/ County, Texas
Defendant (County)
Affidavit of Indigency
(RequesttoNotPay Court Fees)
Use this form to ask the court not to You musteither 1)signthis form In You can be prosecuted Ifyou lie on
charge you for court fees. This form is front of a notary public or 2) sign this this form.
form and sign and attach a completed The court may or may notapprove this
also called an "Affidavit of Inability to
Pay Court Costs" or a "Pauper's Oath." "Unsworn Declaration" form. By requestto notpaycourt fees. Thecourt
You can only use this form If: (1) you signing in front ofa notary, you swear mavorcjer yout0 answerquestions
get public benefits because you are under oath that the information aD0Ut yourfinances at a hearing. At
poor or (2) you can't pay court fees. provided is true and correct. By that hearing you will have to present
The information you give on this form signing and attaching an "Unsworn evidence to theJudge ofyour income
must be current, complete, true and Declaration"1 form, you declare under ancj expenses to prove that you have no
correct. penalty of perjury that the information ability to pay court fees.
provided is true and correct.
O The person who signed this affidavit appeared, In person, before me,the undersigned notary, and stated
under oath:
"My name is VICTOR QUIJANQ Mv phone number Is ( Qfi6&J2254?
"My mailing address is. _ lO&ai
"Myemail address is TARPEST@HOTMAIL.COM
"I am above theage ofeighteen (18) years, and1am fully competent to make this affidavit. I am unable to pay court
costs. The nature and amount ofmyincome, resources, debts, and expensesare described inthisform.
Check ALL boxes thai apply and fill in the blanks describing the amounts and sources ofyour Income.
© "I receive these public benefits/government entitlements that are based on indigency:
• SSI DWIC CS;FoodStamps/SNAP DTANF [^Medicaid • CHIP QAABD
D Needs-based VA Pension O County Assistance, County Health Care, orGeneral Assistance (GA)
• LIS in Medicare ("Extra Help") • Community Care via DADS • Low-Income Energy Assistance
D Emergency Assistance • Child Care Assistance under Child Care and Development Block Grant
• Public Housing • Other: (Describe) . :
If you receive enyofthoabove public benefits, attach proof, andlabel It 'Exhibit Proof ofPublic Benefits"
© "My income sources are stated below. (Check bU that apply)
• Unemployed since: (date) , -or-
fJ9 Wages: I work as a for . FFMPIOYFD
SFI
SELF EMPLOYED, ydurjob (/He Your employer
• Child/spousal support G My spouse's Income or Income from another member of myhousehold (if available)
• Tips, bonuses • Military Housing • Worker's Comp G Disability O Unemployment G Social Security
G Retirement/Pension Q Dividends, interest, royalties G 2nd Job or other income:
(describe)
© "My income amounts are stated below.
(a) My monthly net income after taxes are taken out is: Total income after,taxes -# 1.6QQ
(b) Theamount I receive each month in public benefits is; Total amount received -t 1SL
(c) The amount ofincome from other people in my household is:' Total amount received -t
(d) The amount Ireceive each month from othersources Is: Total amount received ^
(e) My TOTAL monthly Income is Add all sources of income above-* =r •^00-
'List tin's Income only Ifothermembers contribute to your household income.
Page 1 of 2
© TexasLawHetp.org - Affidavit of Indigency, February 2014
About my dependents: "The people who depend on me financiallyare listed below:
Name Age Relationship to Me
WIFE
1 MARIA AMAYA 53_
2 ESTEFANIA QUUANO 2A. OAlffiHTFR
3 .IFSIISOUI.IANO 43- -SON-
4 JUAN QUUANO
QUI i©N-
Jan
ANA UUIJANU %
DAUGHTER
6
© "My property includes: Value* ©"My monthlyexpenses are: Amount
Cash Rent/house payments/maintenance 689
JL5G
Bank accounts, other financial assets (List) Food and household supplies 600
$ 0 Utilities and telephone $ 250
$ Clothing and laundry $_JL
£ Medical and dental expenses E_Q-
Vehicles (cars, boats) (List make andyear) Insurance (life, health, auto, etc)
WINnSTARflR $ 1500 School and child care
$ Vehicle payments
Gas, bus fare, auto repair
•ttr
$ Child / spousal support
Real estate (house or land) (Do not list the house you live in.) Wages withheld by court order
$ 0 Debt payments
$ Other expenses (Describe)
Other property (likejewelry, stocks, etc.) (Describe)
$0
$0
Total value of property -* = $ 1650 | Total monthly Expenses -> = $1 fiiann
"The value is ihe amount the item would sell for less the. amount you still owe on tl (if anything).
t) "My debts include: List debt and amount owed. .
Tolist any otherfacts you want the court lo know, such as unusualmedical expenses, family emergencies, etc., attach another
page to this form and label it"Exhibit: Additional Supporting Facts." Check here ifyou attach another page.Q
@k"l am unable to pay court costs. I verify that the statements made in this affidavit are true and correct."
Your Sidnatui Ygit must either: 1) sign thisform In front of a notary public or
2) sign mis •ign and attach a completed "Unsworn Declaration'' form.
^ Avvr
Vow Date
Notary flits out this section if you
Stattfof Texas are signing in front ofo notary.
Notary stamp here
County of /no-TOs*
Prim tho nameof county where this Affidavit is notarized. I
Sworn to and s]rfbsc?)ibed before me today, ///•-? / ' O .by t/fcJo/ ^Qnu£if),<),0io>/)o.
Printname of persdn who Is signing'this Affidavit.
•^—^.'-**••—g—Xft—*EV->r.—ffi_-/ES.
notary's name.
LINDA CASTRO
My Commission Expires
March 31, 2018
Page 2 of 2
©TexasLawHelp.org - Affidavit ofIndigency, FebrUSry^ffT^P^ *^"SEa,"S£:,"SP
Victor Quijano, Doing Business as Target Pest Control v. Cameron County, City of Brownsville & Brownsville Independent School District
Combined Opinion