05-19-00728-CV — NOTICE: THIS DOCUMENT CONTAINS SENSITIVE DATA .iflrVfrtr ftrn ji — till t& fit C I’— ft’j Cause umber( C /9 erk,s cues fbI in Ins ..H.soN’4—.; tt.l:,,i fl/s Ui.sLJrIU) Plainti 4 to i In the [c’,ecl 20 Pfl j: 29 frfli i.rt(Idl!J.JPIH cf/fit, on lip i:i,vsufl j Q District Court “fl çajourt at Law Justice Cou” Defendan/ctflttt Pr h- and /ast ilmile In of inc poiscn being ‘:ued ) Statement of Inability to Afford Payment of Court Costs or an Appeal Bond My fuN leg name is,k/teFits; flktC :o Last My date of birth is: 4_i/it te5 /-.c;SfrDaW ear My address is: iiun,eI ? Jc..cfr-$ .__% Q (a4rcj . flfl C) My phone number-$f fl-I-, g3. My email: 77 / About my dependents: The people who depend on me financially are listed below. Re/abc is/ic) to Me iZ)rtSs ni/ eli 2- 3 4 5 6 yR 1% 2. Are you represented by L al Aid? LI 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. -or [3 I 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 tating this. or- am not represented by legal aid. I did not apply for representation by legal aid. 3. Do you receive public benefits? [H’not receive needs-based public benefits. - or - Li I receive these public benefitslgovernment entitlements that are based on indigency: as a copy of an eflq’Uilny loin, ortheck I iCneck sQL lroes I/at apply ad at/ad’ proct to this ibm, Slit/I J Food stamps)SNAP 0 TANF L Medicaid IJ CHIP SSI D W1C H MBD LI Public Housing or Section 6 Housing U Low-Income Energy Assistance El Emergency Assistance [ii Telephone Lifeline LI Community Care via DADS LIS in Medicare (Extra Help) U Needs-based VA Pension LI Child Care Assistance under Child Care and Development ck Grant r, gr rstcounttt7t or General As&stance © Form Approved by the Supreme Court of Texas by order in Misc. Docket No. 16-9122 Statement of fnabsfity to Afford Payment of Court Costs Page 1 of 2 4. What is your monthly income and income sources? “I get this monthly income: C in monthly wages. I work as a [7 rev ourjci) t,,Ie “°1lr a— for i9I4c /hc SU rl;Jm3er a1L1 in monthly unemployment. I have been unemployed since (datel public benefits per month. ‘mother people in my household each month: (Lstmityfoiha’inemheiscontnht&wym’r i50B0’d :i;corne.) rom [J Retirement/Pension El Tips, bonuses fl Disability [J Worker’s Comp Social Security Military Housing El Dividends, interest, royalties Child/spousal support U My spouse’s income or income from another member of my household (If avanable) from other jobs/sources of income. (Oesaim& s_i 0 0 is my total monthly income. 5. What is the value of your property? 6. What are your monthly expenses? “My property includes: Value* “My monthly expenses are: Amount Cash $ Ito Rent/house payments/maintenance sQ Bank accounts, other financial assets Food and household supplies Utilities and telephone s%LO 7/ Clothing and laundry $0 // $ ho Medical and dental expenses 2-- OQ Vehiclgs (ca, boats) ;nreke and yea’) Insurance (life, health, auto, etc.) $frC School and child care $ V?0 $v0 Transportation, auto repair, gas $140 Child / spousal support $ Other property (like jewelry, stocks, land, Wages withheld by court order another house, etc.) ,‘\ $ V Debt payments paid to: (List’ svtO s1’O VL’ T al value of property The vaiue is the amount the - $j7 p torn would sell for Total Monthly Expenses les lhe urn owl you sNI owe on d.. it a nyl 111)0 $ —$ 7. Are there debts or other facts explaining your financial situation? “My debts include: (List deaf and anountowedj j /1 • fl f/I vu I if you want the court to consider othcr ñ2cts such as unusual medical expens..s, family erne,genc,os cm. attacl; a,indlcr page to this 1dm, laPsed Exh,bfl Adadianal Supporting Facts.] Chock hem if you attach another page. 8. Decla$ien— I dØefunder penalty of perjury that the foregoing is true and correct. I further swear ff1 cannot afford to pay court costs. Li I cannot furpish n a peal bond or pay a ca d p it to pp al a justice court decision. Mynameis7+LeVInZt 2Z—? I /4 t_,lc My date of birth is; My addr s is ‘t—Y ?z5 C’ - -t ZIP coce y,% cuu:’/ © 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