Fillable AFFIDAVIT OF INDIGENCE (Denton County, Texas)

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AFFIDAVIT OF INDIGENCE (Denton County, Texas)

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  • 20 check-boxes
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Country of origin: US
File type: PDF

U.S.A. forms for Denton County, Texas

BROWSE DENTON COUNTY, TEXAS (TX) FORMS

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DENTON COUNTY Cause No. __________________________________
Defendant Meets Eligibility Requirements ☐ YES ☐ NO
AFFIDAVIT OF INDIGENCE
THIS PORTION TO BE COMPLETED BY OFFICE PERSONNEL ONLY
The State of Texas
vs.
____________________________
County Court Criminal Court No. 2
Offense:
Interpreter required? ☐ Yes ☐ No
If yes, language required:
THIS PORTION TO BE COMPLETED BY OR WITH DEFENDANT
Name__________________________________________________________________________________
Date of Birth _________/_______/________
First Name MI Last Name
Address _______________________________ ____________________ _________________________ ____________ _____________________
Street Apt No. City State Zip Code
Phone Numbers ___________________________ __________________________ _________________________ ________________________
Home Cell Work Family Member
I receive: ☐ Medicaid ☐ SSI ☐ SNAP ☐ TANF ☐ Public Housing
Are you Employed? ☐ Yes ☐ No If yes, where? __________________________________ Type of Work __________________________
Number of Hours per Week: _____________ How long have you worked at this job? _________________
Marital Status : ☐ Single ☐ Married ☐ Divorced ☐ Widowed ☐ Separated
Name of Spouse _______________________________________________________________________________
First MI Last
Persons residing in household
Age
Persons residing in household
RESIDENCE INFORMATION
Rent: yes or no Own: yes or no Reside with family: yes or no Homeless: yes or no
MONTHLY INCOME AND ASSETS
MONTHLY EXPENSES
My gross income
$
Rent/Mortgage
$
Spouse’s gross income
$
Utilities (Elec., Gas, Water)
$
Child Support (Received)
$
Total Child Expenses (Including Child
Support Paid)
$
SNAP (Food Stamps)
$
Total Food Expenses
$
Social Security/Disability
$
Transportation Costs
$
Other Government Check
$
Cell/home phone
$
Other Income
$
Probation fees
$
Assets (car, house, etc.)
$
Medical Expenses / Health Insurance
$
TOTAL MONTHLY INCOME
AND ASSETS
$
Minimum Monthly Credit Card
Payment
$
TOTAL MONTHLY EXPENSES
$
Defendant’s Oath
On ___________________________, I certify the above financial affidavit to be correct and further certify that I have
been advised of my rights to representation by counsel for the charge(s) listed above pending against me and that I
am without means to employ counsel of my own choosing and hereby request the Court to appoint counsel for me.
Alternatively, I certify that the interests of justice require court-appointed representation for me before this Court.
I understand that if I intentionally or knowingly give false information either in this affidavit or during the hearing
on this motion, that I may be prosecuted for the offense of aggravated perjury, a third degree felony, punishable by
imprisonment not to exceed (10) years or less than 2 years and a fine not to exceed ten thousand dollars
($10,000.00).
________________________________ ____________
Defendant’s Signature Date
Administered Oath (Judge ONLY)
SUBSCRIBED and SWORN to before me, the undersigned authority, on _______________________.
________________________________
Judge Presiding
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AFFIDAVIT OF INDIGENCE (Denton County, Texas)

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Completed 21 January 2021

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