Fillable Court Costs or an Appeal Bond Statement of (Travis County Information Technology Services)

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Court Costs or an Appeal Bond Statement of (Travis County Information Technology Services)

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NOTICE: THIS DOCUMENT CONTAINS SENSITIVE DATA
© 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 1 of 2
Statement of Inability to Afford Payment of
Court Costs or an Appeal Bond
1. Your Information
My full legal name is: My date of birth is: / /
First Middle Last Month/Day/Year
My address is: (Home)
(Mailing) ___________________________________________________________________________________
My phone number: My email:
About my dependents: me financially are listed below.
Name
Age
Relationship to Me
1
2
3
4
5
6
2. Are you represented by Legal Aid?
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
.
-or-
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 stating this.
or-
I am not represented by legal aid. I did not apply for representation by legal aid.
3. Do you receive public benefits?
I do not receive needs-based public benefits. - or -
I receive these public benefits/government entitlements that are based on indigency:
(Check ALL boxes that apply and attach proof to this form, such as a copy of an eligibility form or check.)
Food stamps/SNAP TANF
Medicaid CHIP
SSI
WIC
AABD
Public Housing or Section 8 Housing Low-Income Energy Assistance
Emergency Assistance
Telephone Lifeline Community Care via DADS
Needs-based VA Pension
Child Care Assistance under Child Care and Development Block Grant
County Assistance, County Health Care, or General Assistance (GA)
O
ther
:
Cause Number:
Cause Number when you file this form)
Plaintiff:
In the (check one):
(Print first and last name of the person filing the
lawsuit
.
)
District Court
County Court / County Court at Law
Justice Court
And
Court
Number
Defendant:
Texas
(Print first and last name of the person being sued
.
)
County
© 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
4. What is your monthly income and income sources?
I get this monthly income:
$ in monthly wages. I work as a for .
Your job title Your employer
$ in monthly unemployment. I have been unemployed since (date) .
$ in public benefits per month.
$ from other people in my household each month: (List only if other members contribute to your
household income.)
$ from Retirement/Pension Tips, bonuses Disability mp
Social Security Military Housing Dividends, interest, royalties
Child/spousal support
member of my household (If available)
$ from other jobs/sources of income. (Describe)
$ is my total monthly income.
5. What is the value of your property? 6. What are your monthly expenses?
property includes: Value*
My monthly expenses are:
Amount
Cash
$
Rent/house payments/maintenance
$
Bank accounts, other financial assets Food and household supplies
$
$
Utilities and telephone
$
$
Clothing and laundry
$
$
Medical and dental expenses
$
Vehicles (cars, boats) (make and year) Insurance (life, health, auto, etc.)
$
$
School and child care
$
$
Transportation, auto repair, gas
$
$
Child / spousal support
$
Other property (like jewelry, stocks, land,
another house, etc.)
Wages withheld by court order
$
$
Debt payments paid to: (List)
$
$
$
$
$
Total
value of property
$
Total
Monthly Expenses
$
*The value is the amount the item would sell for less the amount you still owe on it, if anything.
7. Are there debts or other facts explaining your financial situation?
debts include:
(List debt and amount owed)
(If you want the court to consider other facts, such as unusual medical expenses, family emergencies, etc., attach another page to
this form labeled ) Check here if you attach another page.
8. Declaration
I declare under penalty of perjury that the foregoing is true and correct. I further swear:
I cannot afford to pay court costs.
I cannot furnish an appeal bond or pay a cash deposit to appeal a justice court decision.
My name is . My date of birth is : / / .
My address is
Street City State Zip Code Country
signed on
/ /
in
County,
Signature Month/Day/Year
county name State
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Court Costs or an Appeal Bond Statement of (Travis County Information Technology Services)

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Completed 26 January 2021

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