--jLse Number. ^VVj:iticrer, n rhe 1*, 3&rP ^_csc^s«- -* ^'Strict Court ^ &06&H& ~ Cc""ty Court at Law Affidavit of Indigency %& '% % -'se^formioaskmecoorinono *«* f^'vou for court fees. This farm ""ou can b. PfoaaeuS^ftfe.,, on this farm. ""Pu •<• .. 'am-wC0SlS0r3 pauper'57 -am 'ou can only us. m farm,f- ™9 court may ormayno| M/oU,eiDuol,cl)enef„a6 ;oUa.ooor0ri2)youcantpav' •nformahonprov,^,, r"e court may order you to a„!Z' :ounlees. luesdon, aoou, your«££« £*' 'r-,™»"lm'a"<"'you9,veo"'n's ^v.,0 present ev,danc9To,^ i"d9« olyour.neome ana exl* 'oorov„ha,younav9an^^»nses DJh.p.rlwnwhos| iT» ti. °'r~«- correct. — "uuaana pay court "' Pay fees. °a0,"1 »»•« you nave no abnir. court tees. ua°wty to undafowh: ""* ",,d,v', appeared, in pwaon b#fcM „ , r * 5 M ^ S S T ^ 7 ^VPnon.nun1t!afisl^^^ ~3.m.na.r.anaa™u-^^ ;^:im'mw-'^-'---..»^.Z •OTd8,08n8"ar'^-^.nc,owc°- _- eMwrny^aMM. - chili r .""Ca"*" 0A°S NLoJln^ ^ ^"^ — Wages: I wont as a - Child/5Dousal suoport3t t- 'Z .^ My SD~~~~':u"0<>""» - ''3uf^«* "" *' ' 'or ^___ °) Th, amoijn,, a""'*"» *• taken out ia: =) Th.amoumotaV^^r'"°Ud,ie'""«*<* "V T3JT* *.•„, >» Tha .mount, race v, , cn 0e°°"'" "* nouMn™ *' ?". M "-'«? ~ctf,rf •<"«•« o/rwm.,00^. = S j&i. -\%m 1 of 2 -' -douimy d9p<,naBn(S: •rhe oeccie v • .a >"o cecena en me financially are listed below: '5 My property includes: value' Cash 3"My monthly expenses are: s Amount 3ank accounts, other financial assets ,i,„, Sent/house payments/maintenance Pood and household supplies Utilities and telephone . 3 Clothing and laundry 5 Vehicles (cars, boats)«.,» ma*9 ana year; Medical and dental expenses . 5_ insurance (life, health, auto, etc) School and child care . S Vehicle payments Gas, bus fare, auto repair *eal estate (house or land) too nottta 1ZZ Ch"d' SP°UMl S4Jpport ^"••"•^-•^•••J Wages withheld by cou court order —-* """" ~ • * Debt payments Other property (like jewelry, stocks, etc.) tOtscribmf - Other expense tOmtwumk Total value ofproperty ^=$ C *My debts include: l-,, -.., ,.„.„.„.,, ... ^ ^ cxv are true and correct.1 J Your Signature. ' *:j > uJ33e~&0a~#-t'Jst '. -•:• ;f ;''C» '~rrn State of Texas County of — '-~f •»« - n/r»a -. ^»^^-^—^— _ - •-'-<-••< ...*e .-ra,--aw ,.ra/- Sworn :o and sufiscrceo before me today. .-y •"-.u*™.*, .^eew^^wcy NovrrcuOK '*;• 2. ot 2 • V Unsworn Declaration (Texas Civil Practice and Remedies Code, Section 132.001) My name is: &J CLC/Jn^ /2g ^ r Aj ^/^^//fO^S M,ddle j^— my date of birth is: s/ I ^5~ I ZfcL and Year myaddressis:S**>rs»w, f ,y.(^ «V -rv State wro —~^— Zip Code and KIA-CJC^ Country (Ifyou am incarcerated, you must also include the following information.) My inmate identifying number, if any, is: /'Cj S~$' Y^^L. Iam presently incarcerated in: Corrections Unit Name in: City Counil State Zip Code Ideclare under penalty of perjury that all information in the attached document titled. Name of Document 7 • • •' ,S trUe and COITOCt Signed in J/H-^ County County, -t&c/h State on this date: _/0__ I<£<£. / /JT_ Month Day Year Your Signature " ~ ©TexasLawHelp.org - Unsworn Declaration, August 2012 Page 1 of 1