Preview
WARNING: Without the advice and help of an attorney, you may be putting yourself, your personal property, and your money at
risk. To get a referral to an attorney, call the State Bar of Texas Lawyer Referral Information Service at 1-800-252-9690. If you area
victim of domestic violence, or if at any time you feel unsafe, you can get confidential help from the Nationgl@praBstic RQ
Hotline at 1-800-799-7233 or legal help from the Texas Advocacy Project Family Violence Legal Line at 1-90PBEERRECOT Q
(Print your answers in blue ink) Atlee SC Cie:
Cause Number:
A: -
0 JUN 05 2024
(The Clerk's office will fill in the Cause Number when you file this form)
IN THE MATTER OF THE MARRIAGE OF Y Melisa Miller, Bietrict Cler k
tgo! f 61 jexas
Petitioner: Step he PY ihe [Feiss the (check one): aputy
(Print firkt, middie, and last name of the spouse By County Court at
filing for divorce) mM eforctct Court Law of:
(Court Namber)
he
And
Respondent 4 f ists wl feos
(Print first, middle, andfast name of other spouse)
ow
(County)
Ls recast ,7Z_ County, Texas
Affidavit of Indigency
(Divorce Set 1 - Uncontested, No Minor Children, No Real Property)
WARNING: Read all of the Instructions for Divorce Set 1 before filling out this form.
WY
The person who signed this affidavit appeared, i erson, before me, the undersigned nota ler, oa!
h,
“My name is Wh py MEE PIF My pho! number is:
“My mailing addre: is. OD YEE Dr pleut A VK KPA EE
“lam above the age of eighteen (18) years, and | am fully competent to make this affidavit. | am unable to pay court costs.
The nature and amount of my income, resources, debts, and expenses are described in this form.
Check ALL boxes that apply and fill in the blanks describing the amounts and sources of your income.
“| receive these public benefits/government entitlements that are based on indigency: Ossi Owic
C Food stamps/SNAP TANF CO Medicaid CHIP CJ Needs-based VA Pension
County Assistance, County Health Care, or General Assistance (GA) 1] Community Care via DADS
(J AABD CH Public Housing [1] Low-Income Energy Assistance [_] LIS in Medicare (“Extra Help”)
LJ Emergency Assist anes O Child Care Assistance under Child Care and Development Block Grant
Other : -
if you receive any of the above public benefits, you may attach proof to this form and label it “Exhibit: Proof of Public Benefits.”
“My income sources are stated below (check ail that apply).
[Unemployed since:
OF; Date
Le
Wages: | work as a Pe - for (eC 4 Yer feorsana Seri
Your job title Your employer
C Child/spousal support [[] My spouse's income or income from another member of my household (if available)
[J Tips, bonuses (_] Military Housing [] Worker's Comp [] Disability [] Unemployment [_] Social Security
- ()Retirement/Pension [] Dividends, interest, royalties [1 2™ job or other income:
Describe
“My income amounts are stated below.
(A) My monthly take-home wages: Total amount received> $i 140
(B) The amount | receive each month in public benefits is: Total amount received —> $ A
(C) The amount of income from other people in my household:
(list this income only if other members contribute to your household income ) Total amount received —> $
(D) The amount | receive each month from other sources is: Total amount received > $_-T-
(E) My TOTAL monthly income Add all sources of income above-> =$ b
© Form Approved by the Supreme Court of Texas by order in Misc. Docket No. 13-9085 (June 17, 2013)
Affidavit of Indigency (Divorce Set 1 - Uncontested, No Minor Children, No Real Property) Page 1 of 2
5
About my dependents:
“The people who depend on me financially are listed below:
17
Name Age Relationship to Me
1_ 24, 1L'sax Pers 3 27, Gn
“My property includes: Value’ “My monthly expenses are:
Cash $ Rent/house payments/maintenance
unt
a2,
Bank accounts, other financial assets (Li oO Food and household supplies $ Lo?
Utilities and telephone
$ Clothing and laundry
$ Medical and dental expenses
Vehicles (cars, boats) (List make and year) y Insurance (life, health, auto, etc.)
School and child care
$ Transportation, auto repair, gas
$ Child / spousal support
Other property (like jewelry, stocks, etc.) (Describe) Wages withheld by court order
$ Debt payments paid to: (List)
$
Total value of property >
EsZ| Total Monthly Expenses —> ES
*The value is the amount the item would sell for less the amount you still owe on it, if anything
S23
“My debts include: (List debt and amount owed) ZA, ‘A,we pT 2 c Z VU af.
“lam unable to pay court costs. | verify that the statements made in this affidavit are true and correct.”
To list any other facts you want the court to know, such as unusual medical expenses, family emergencies, etc., attach another page to
this form and label it “Exhibit: Additional Supporting Facts.” Check here if you attach another page.
Do not sign uj ygu areif front of a notary.
DAS
——
Signature of Person4igning Affidavit
é
Date
2Y
Notary fills out below.
State of Texas, County of Ao tp nee lV
(Print the name of Gauhty where this Affidavit is mae
Sworn to ang subscribed before me, the undersigned notary, on this date: 7 193 924 ot SEB amet)
lees
month day year time (circle one)
wy (PrintSteglen A. tetyyjsor
name te who &/signing this Affidavid NOT the notary’s name.)
» Signat;
ANDREW PEREZ
My Notary ID # 130769630
Expires October 7, 2024
© Form Approved by the Supreme Court of Texas by order in Misc. Docket No. 13-9085 (June 17, 2013)
Affidavit of Indigency (Divorce Set 1 - Uncontested, No Minor Children, No Real Property) Page
2 of 2
Preview
WARNING: Without the advice and help of an attorney, you may be putting yourself, your personal property, and your money at risk. To get a referral to an attorney, call the State Bar of Texas Lawyer Referral Information Service at 1-800-252-9690. If you area victim of domestic violence, or if at any time you feel unsafe, you can get confidential help from the Nationgl@praBstic RQ Hotline at 1-800-799-7233 or legal help from the Texas Advocacy Project Family Violence Legal Line at 1-90PBEERRECOT Q (Print your answers in blue ink) Atlee SC Cie: Cause Number: A: - 0 JUN 05 2024 (The Clerk's office will fill in the Cause Number when you file this form) IN THE MATTER OF THE MARRIAGE OF Y Melisa Miller, Bietrict Cler k tgo! f 61 jexas Petitioner: Step he PY ihe [Feiss the (check one): aputy (Print firkt, middie, and last name of the spouse By County Court at filing for divorce) mM eforctct Court Law of: (Court Namber) he And Respondent 4 f ists wl feos (Print first, middle, andfast name of other spouse) ow (County) Ls recast ,7Z_ County, Texas Affidavit of Indigency (Divorce Set 1 - Uncontested, No Minor Children, No Real Property) WARNING: Read all of the Instructions for Divorce Set 1 before filling out this form. WY The person who signed this affidavit appeared, i erson, before me, the undersigned nota ler, oa! h, “My name is Wh py MEE PIF My pho! number is: “My mailing addre: is. OD YEE Dr pleut A VK KPA EE “lam above the age of eighteen (18) years, and | am fully competent to make this affidavit. | am unable to pay court costs. The nature and amount of my income, resources, debts, and expenses are described in this form. Check ALL boxes that apply and fill in the blanks describing the amounts and sources of your income. “| receive these public benefits/government entitlements that are based on indigency: Ossi Owic C Food stamps/SNAP TANF CO Medicaid CHIP CJ Needs-based VA Pension County Assistance, County Health Care, or General Assistance (GA) 1] Community Care via DADS (J AABD CH Public Housing [1] Low-Income Energy Assistance [_] LIS in Medicare (“Extra Help”) LJ Emergency Assist anes O Child Care Assistance under Child Care and Development Block Grant Other : - if you receive any of the above public benefits, you may attach proof to this form and label it “Exhibit: Proof of Public Benefits.” “My income sources are stated below (check ail that apply). [Unemployed since: OF; Date Le Wages: | work as a Pe - for (eC 4 Yer feorsana Seri Your job title Your employer C Child/spousal support [[] My spouse's income or income from another member of my household (if available) [J Tips, bonuses (_] Military Housing [] Worker's Comp [] Disability [] Unemployment [_] Social Security - ()Retirement/Pension [] Dividends, interest, royalties [1 2™ job or other income: Describe “My income amounts are stated below. (A) My monthly take-home wages: Total amount received> $i 140 (B) The amount | receive each month in public benefits is: Total amount received —> $ A (C) The amount of income from other people in my household: (list this income only if other members contribute to your household income ) Total amount received —> $ (D) The amount | receive each month from other sources is: Total amount received > $_-T- (E) My TOTAL monthly income Add all sources of income above-> =$ b © Form Approved by the Supreme Court of Texas by order in Misc. Docket No. 13-9085 (June 17, 2013) Affidavit of Indigency (Divorce Set 1 - Uncontested, No Minor Children, No Real Property) Page 1 of 2 5 About my dependents: “The people who depend on me financially are listed below: 17 Name Age Relationship to Me 1_ 24, 1L'sax Pers 3 27, Gn “My property includes: Value’ “My monthly expenses are: Cash $ Rent/house payments/maintenance unt a2, Bank accounts, other financial assets (Li oO Food and household supplies $ Lo? Utilities and telephone $ Clothing and laundry $ Medical and dental expenses Vehicles (cars, boats) (List make and year) y Insurance (life, health, auto, etc.) School and child care $ Transportation, auto repair, gas $ Child / spousal support Other property (like jewelry, stocks, etc.) (Describe) Wages withheld by court order $ Debt payments paid to: (List) $ Total value of property > EsZ| Total Monthly Expenses —> ES *The value is the amount the item would sell for less the amount you still owe on it, if anything S23 “My debts include: (List debt and amount owed) ZA, ‘A,we pT 2 c Z VU af. “lam unable to pay court costs. | verify that the statements made in this affidavit are true and correct.” To list any other facts you want the court to know, such as unusual medical expenses, family emergencies, etc., attach another page to this form and label it “Exhibit: Additional Supporting Facts.” Check here if you attach another page. Do not sign uj ygu areif front of a notary. DAS —— Signature of Person4igning Affidavit é Date 2Y Notary fills out below. State of Texas, County of Ao tp nee lV (Print the name of Gauhty where this Affidavit is mae Sworn to ang subscribed before me, the undersigned notary, on this date: 7 193 924 ot SEB amet) lees month day year time (circle one) wy (PrintSteglen A. tetyyjsor name te who &/signing this Affidavid NOT the notary’s name.) » Signat; ANDREW PEREZ My Notary ID # 130769630 Expires October 7, 2024 © Form Approved by the Supreme Court of Texas by order in Misc. Docket No. 13-9085 (June 17, 2013) Affidavit of Indigency (Divorce Set 1 - Uncontested, No Minor Children, No Real Property) Page 2 of 2