Statement of Inability to Afford Payment of Court Costs Form

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© 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: “The people who depend on me financially are listed below. 
Relationship to Me 
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 
gave me as ‘Exhibit: Legal Aid Certificate. 
 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.  
 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  LIS in Medicare (“Extra Help”) 
 Needs-based VA Pension  Child Care Assistance under Child Care and Development Block Grant 
 County Assistance, County Health Care, or General Assistance (GA) 
Cause Number:    
  (The Clerk’s office will fill in the 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 
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    Worker’s Comp 
 Social Security   Military Housing   Dividends, interest, royalties  
 Child/spousal support 
 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 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?  
“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.   
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 
Digitized 9/9/2016 by GFS