• •' »y* £ -,••: ) la-is^aoogo-CV FILED IN COURT OF APPEALS 12th Court of Appeals DfeMct / NOTICE: THIS FORM CONTAINS SENSITIVE DATA. Cause Number: The Clerk's office will fill in the Cause Numberwhen you ft J Mis ft irm.) APR-9:2015. n the (checkone) -I Petitioner/ TYLER TEXAS Plaintiff y^>r\ ^5JrYN ST District cjou£ATHY S. LUSfocjpLEFfcte i*i. (Court Number) Q County Court at Law • Justice of the Peace Respondent/ Defendant £2s *o o (County) 1*^30>, Are>.C*xjirse. , ^TTM. ^CO^i "My email address is g_dcWors <^Ci'< (€) c^CTscri i'.. C^sv^ -? to make this affidavit. Iam unable to pay court "I am above the age of eighteen (18) years, and I am fully competent costs. The nature and amount of my income, resources, debts, and expenses are described in this form. Check ALL boxes that apply and fill in the blanks describing the amounts andsources ofyourincome. ® "I receive these public benefits/government entitlements thatare based on indigency: • SSI DWIC • Food Stamps/SNAP • TANF • Medicaid • CHIP • AABD • Needs-based VA Pension • 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 Q Other: (Describe) Ifyou receive any of the above public benefits, attach proof and label it "Exhibit: Proof of Public Benefits" ® "My income sources are stated below. (Check all that apply) D Unemployed since: (date) -or- -K'Wages: Iwork as a Z^Wr?,I f l A ' . ^ /ec^-A - Your job title f°r feu/fc^ YourPloAu-k employer Re^l-Lf • Child/spousal support • My spouse's income or income from another member of my household (if available) • Tips, bonuses • Military Housing Q Worker's Comp • Disability • Unemployment • Social Security • Retirement/Pension [J Dividends, interest, royalties D 2nd job orother income: (describe) © "My income amounts are stated below (a) My monthly net income after taxes are taken out is: Total income after taxes -> o <3 (b) The amount I receive each month in public benefits is: Total amount received -* $ -& (c) The amount of income from other people in my household is:* Total amount received -> $ -0- (d) The amount I receive each month from other sources is: Total amount received -# & (e) My TOTAL monthly income is Add allsourcesofincome above *List this income only if other members contribute to your household income. = IjiBaE0 o Page 1 of 2 ©TexasLawHelp.org - Affidavit of Indigency, February 2014 © About my dependents: "The people who depend on me financially are listed below: Name Age Relationship to Me 1 2 5 6 © "My property includes: ©"My monthly expenses are: Amount Cash Rent/house payments/maintenance $ <3os-go Bank accounts, other financial assets (List) Food and household supplies $ ?ko: °o $ -&- Utilities and telephone $ 2ooc0 $ lS^ Clothing and laundry $ •& Medical and dental expenses oQ jSl J4&- Vehicles (cars, boats) (List make andyear) Insurance (life, health, auto, etc) -&- School and child care -e- i $ -£5- Vehicle payments -e- **S- Gas, bus fare, auto repair -er $ &- Child / spousal support Real estate (house or land) (Do notlist thehouseyoulive in.) Wages withheld by court order $ u- $ jg£r Debt payments -e- Other expenses (Describe) Other property (like jewelry, stocks, etc.) (Describe) -<& $ ^^ •©- •G- Total value ofproperty -* |= $fx3Q-°° Total monthly Expenses =$/)9£f?Q- CO 'The value is the amount the item would sell for less the amount you still owe on it (ifanything). © "My debts include: List debt and amount owed. s*\— Tolist any other facts you want the court to know, such as unusual medical expenses, family emergencies, etc., attach another page to this form and label it "Exhibit: Additional Supporting Facts." Check here ifyou attach anotherpage.O ® "I am unable to pay court costs. Iverify that the statements made in this affidavit are true and correct." ® Your Signature. You must either: 1) sign this form in front ofa notary public or 2) sign this/prm and sigffhpd attach a completed "Unsworn Declaration'' form. Notary fills out this section if you State of Texas are signing in front of a notary. County of "fcyyJUT" Notary stamp here Print the name of county where this Affidavit is notarized. Sworn to and subscribed before me today, Any}) 7 2f>i % , by &o£&\ f\wi&S 7)\XOH. \Lf fih7 /] y /^» ' Plato Date Drirtt name Print rt**ma of r\f person r\esrt*s\n ttihn who isle* signing n!nn;'nA this fkiV. Affidavit. NOT the notary's name. Notary's Signature r**-****!^™**********^**************^^^^ SHILU SHRESTHA NOTARY PUBLIC Page 2 of 2 © TexasLawHelp.org - Affidavit of Indigency, STATE OF TEXAS MYCOMM.EXR 11/08/17