© 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
$ from Retirement/Pension Tips, bonuses Disability Worker’s Comp
Social Security Military Housing Dividends, interest, royalties
My spouse’s income or income from another 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?
“My monthly expenses are:
Bank accounts, other financial assets
Food and household supplies
Medical and dental expenses
Vehicles (cars, boats) (make and year)
Insurance (life, health, auto, etc.)
Transportation, auto repair, gas
Other property (like jewelry, stocks, land,
another house, etc.)
Wages withheld by court order
Debt payments paid to: (List)
*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?
“My 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 “Exhibit: Additional Supporting Facts.”) Check here if you attach another page.
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