On March 14, 2024 a
Statement of Inability to Afford Payment of Court Costs or an Appeal Bond - Indigency Oath Filed
was filed
for Divorce - No Children
in the District Court of Montgomery County.
Preview
NOTICE: THIS DOCUMENT CONTAINS SENSITIVE DATA
- -
Cause Number:
(The Clerk's office wil fill in the Cause Number when you file this form)
SGlery Pussetf
o th
Plaintiff: In th (check one);
(Print first and ldst name of the person filing the lawsuit.) [2 District Court
‘out LJ County Court / County CSUAAGLBYUND FiLeD
And Number 1 Justice Court IR RECORD
Defendant: a At AFP o'clock AM
(Print first and last nat ime of the person being sued.) Montgpeersy Toes
MAR 1 4°2024
Statement of Inability to Afford Payment of Melisa Miller, District Clerk
Court Costs or an Appeal Bond lontgompery Gounty, Texas
1. Your Information
oibvehig™ A Deputy
My full legal name is: 2: USSe. My date of birth is: OF 1) F/55
First fiddle Last Month/Day/Year
My address is: (Home). The t#
(Maing) Some WS \pove.
My phone number:
%3le" 224° G74 My email: +0, 5 asl. Co
About my dependents: “The people who depend on me financially are listed below.
Name Age Relationship to Me
2. Are you represented by Legal Aid?
[11 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. | have attached the certificate the legal aid provider
gave me as ‘Exhibit: Legal Aid Certificate.
-or-
(1 | asked a legal-aid provider to represent me, and the provider determined that | am financially eligible
for representation, but the provider could not take my case. | have attached documentation from
legal aid stating this.
or-
i! am not represented by legal aid. | did not apply for representation by legal aid.
3. Do you receive public benefits?
(| do not receive needs-based public benefits. - or «
(1 [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.)
(C1 Food stamps/SNAP CITANF FA Medicaid Ocuip Ossi Cwic [lAasp
(1 Public Housing or Section 8 Housing [_] Low-Income Energy Assistance [] Emergency Assistance
2 Telephone Lifeline (1 Community Care via DADS [Ls in Medicare (“Extra Help”)
(Cl Needs-based VA Pension [[] Child Care Assistance under Child Care and Development Block Grant
(1 County Assistance, unty Health Care, or General Assistance (GA)
Mother: Wetive = Set income
© 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
4, What is your monthly income and income sources?
“| get this monthly income:
S, in monthly wages. | work as a for
Your job title Your employer
$ in monthly unemployment. | 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.
$], 090.% from Retirement/Pension Tips, bonuses [J Disability D Workers Comp
Social Security C1] Military Housing [J Dividends, interest, royalties
{J Child/spousal support
My spouse's income or income from anather member of my household (if avaitable)
§ from other jobs/sources of income. (Describe)
$ 0 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: 1 Amount
Cash $ Rent/house payments/maintenance $
Bank accounts, other financial assets Food and household supplies $250
$ Utilities and telephone $ 3U5S>
§ Clothing and laundry $ Fo
$ Medical and dental expenses §
Vehicles (cars, boats) (make and year) Insurance (life, health, auto, etc.) g'2oo.
Grow 1294 $ Schoo! and child care $
“e700.
$ Transportation, auto repair, gas $ /00.‘
$ Child / spousal support
Other property (like jewelry, stocks, land, Wages withheld by court order
another house, etc.)
$ Debt payments paid to: (List)
$
$
Total value of property >$ Total Monthly Expenses > $ 2S_
“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 fo
this form labeled “Exhibit: Additional Supporting Facts.") Check here if you attach another page.
8. Declaration
| declare under penalty of perjury that the foregoing is true and correct. | further swear:
$241 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 MSSe ay ate of birthis:09 /1%/55
My address is q lous F43tS— tyome” y
et City State Zip Code Country
»
Signatdra
signed on,3 J
Month/Day/Year
124 inMontyomery
county nathe
county, aiexas
© 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
Document Filed Date
March 14, 2024
Case Filing Date
March 14, 2024
Category
Divorce - No Children
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