On December 17, 2015 a
Party Statement
was filed
involving a dispute between
Lacy, Michael Damon,
and
Lacy, Ramonia Gail,
for Divorce - No Children
in the District Court of Smith County.
Preview
NOTICE: THIS FORM CONTAINS SENSITIVE DATA.
Cause Number: I b ’ (00‘
' 5/ u
Aliyah Pt.
lln /‘
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‘
(The Clerk’s office will
The Cause Number when you flle this form.) .
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Inthe (check one): ,
.
’
Petitioner/ , . t
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Plaintiff flZ/r/wgfl Amaze/7 D960 agglmammew.
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DIST OURi
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9;.
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(Court Number) County Court at Law
E] Justice of the Peace ' is
74:4“?
RSSPONdGW [67/77/124 gfi/V Mdé/
Defendant
'
/ V6177 I +11
(County)
County. Texas ”Vi-m
Affidavit of lndigency
(Request to Not Pay Court Fees)
Use this form to ask the court not to You must either 1) sign this form in You can be prosecuted if you lie on
charge you for court fees. This form is front of a notary public or 2) sign this this form.
also called an “Affidavit of Inability to form and sign and attach a completed The court may or may not approve this
Pay Court Costs" or a “Pauper's Oath." "Unsworn Declaration" form. By
request to not pay court fees. The court
You can only use this form if: (1) you signing In front of a notary, you swear
may order you to answer questions
get public benefits because you are under oath that the information about your finances at a hearing. At
poor or (2) you can’t pay court fees. provided is true and correct. By that hearing you will have to present
The information you give on this form signing and attaching an “Unsworn evidence to the Judge of your income
must be current, complete, true and Declaration" form, you declare under
and expenses to prove that you have no
correct. penalty of perjury that the information
_ . ability to pay court fees.
provrded rs true and correct.
(D The person who signed this affidavit appeared. In person, before me. the undersigned
notary, and stated
under oath:
“My name is My phone number Is -
5 )
“My mailing address is
“My email address Is
“I am above the age of eighteen (18) years, and I am fully competent to make this affidavit. I 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.
® "I receive these public benefits/government
entitlements that are based on indigency:
E] SSI E] WIC E] Food Stamps/SNAP El TANF El Medicaid D CHIP CI AABD
E] Needs-based VA Pension El County Assistance. County Health Care. or General Assistance (GA)
I] US in Medicare ("Extra Help") CI Community Care via DADS CI Low-Income Energy Assistance
CI Emergency Assistance CI Child Care Assistance under Child Care and Development Block Grant
[:1 Public Housing [Z] Other:(Describe)
If you receive any of the above public benefits, attach proof and label it “Exhibit: Proof of Public Benefits”
"My Income sources are state
(3)
I’Unemployed since:
El Wages: I work as a
(date) j
[/7 I
beio
{214/
. (Check allthat apply)
ya0f) (IiI -Of-
for
Your job title Your employer
E] Child/spousal support C] My spouse's Income or income from another member of my household (lfavallable)
[I Tips, bonuses [I Military Housing [:1 Worker's Comp E] Disability E] Unemployment [I Social Security
I] Retirement/Pension E] Dividends, interest. royaltiesI] 2"" job or other income:
@ "My Income amounts are stated below. (describe)
(a) My monthly net income after taxes are taken out is:
(b) The amount i receive each month in public benefits is:
am
Total income —» 5 fl. 0 0
+
Total amount received -+ s (g: Q g)
(c) The amount of income from other people in my household is:" +
Total amount received
—+ 5 4'2 (>0
(d) The amount I receive each month from other sources is: Total amount received
—» + s g, 0;")
(a) My TOTAL monthly income is =
Add all sources of income above—t»
*List this income only if other members contribute to your household income.
$( .3
I (if?
© TexasLawHelp.crg - Affidavit of lndigency, Febmary 2014 Page1 of 2
(5) About my dependents: “The people who depend on me flnancially are
listed below:
Name
Age Relationship to Me
1
2
3
4
5
6
© “My property Includes: Value‘ @"My monthly expenses are: Amount
Cash 5 Q
Bank accounts, other financial assets (List)
,C)C> Rentlhouse payments/maintenance
s C) (510
s O, C"): i
Food and household supplies
Utilities and telephone
s Q aa
/)
3 Q €35)
()é) Clothing and laundry
M
$
0l
,
00 3 £2, 9;";
$ Medical and dental expenses
Vehicles (cars, boats) (List make and year)
$ Q, Q‘&
Insurance (life, health. auto. etc)
s C) 00 School and child care
3 Q Qfg
if‘. /j() Vehicle payments
s C"; 5g)
Gas, bus fare, auto repair 0/ (I)
5 /), 06>
Real estate (house or land) (Do not list the house you live
Child / spousal support
s d? O /
L1 >7 00
In.) Wages withheld by court order
Debt payments
s C) (If)
(‘2, 043
'
)6.)
$
Other property (like jewelry, stocks. etc.)
Other expenses (Describe) s f) , (>
Document Filed Date
December 17, 2015
Case Filing Date
December 17, 2015
Category
Divorce - No Children
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Preview
NOTICE: THIS FORM CONTAINS SENSITIVE DATA. Cause Number: I b ’ (00‘ ' 5/ u Aliyah Pt. lln /‘ // ‘ (The Clerk’s office will The Cause Number when you flle this form.) . I Qfl x «-7, 1,,7 _ Inthe (check one): , . ’ Petitioner/ , . t g? Plaintiff flZ/r/wgfl Amaze/7 D960 agglmammew. .. DIST OURi 7‘’ 9;. / , ‘ ’ ‘ (Court Number) County Court at Law E] Justice of the Peace ' is 74:4“? RSSPONdGW [67/77/124 gfi/V Mdé/ Defendant ' / V6177 I +11 (County) County. Texas ”Vi-m Affidavit of lndigency (Request to Not Pay Court Fees) Use this form to ask the court not to You must either 1) sign this form in You can be prosecuted if you lie on charge you for court fees. This form is front of a notary public or 2) sign this this form. also called an “Affidavit of Inability to form and sign and attach a completed The court may or may not approve this Pay Court Costs" or a “Pauper's Oath." "Unsworn Declaration" form. By request to not pay court fees. The court You can only use this form if: (1) you signing In front of a notary, you swear may order you to answer questions get public benefits because you are under oath that the information about your finances at a hearing. At poor or (2) you can’t pay court fees. provided is true and correct. By that hearing you will have to present The information you give on this form signing and attaching an “Unsworn evidence to the Judge of your income must be current, complete, true and Declaration" form, you declare under and expenses to prove that you have no correct. penalty of perjury that the information _ . ability to pay court fees. provrded rs true and correct. (D The person who signed this affidavit appeared. In person, before me. the undersigned notary, and stated under oath: “My name is My phone number Is - 5 ) “My mailing address is “My email address Is “I am above the age of eighteen (18) years, and I am fully competent to make this affidavit. I 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. ® "I receive these public benefits/government entitlements that are based on indigency: E] SSI E] WIC E] Food Stamps/SNAP El TANF El Medicaid D CHIP CI AABD E] Needs-based VA Pension El County Assistance. County Health Care. or General Assistance (GA) I] US in Medicare ("Extra Help") CI Community Care via DADS CI Low-Income Energy Assistance CI Emergency Assistance CI Child Care Assistance under Child Care and Development Block Grant [:1 Public Housing [Z] Other:(Describe) If you receive any of the above public benefits, attach proof and label it “Exhibit: Proof of Public Benefits” "My Income sources are state (3) I’Unemployed since: El Wages: I work as a (date) j [/7 I beio {214/ . (Check allthat apply) ya0f) (IiI -Of- for Your job title Your employer E] Child/spousal support C] My spouse's Income or income from another member of my household (lfavallable) [I Tips, bonuses [I Military Housing [:1 Worker's Comp E] Disability E] Unemployment [I Social Security I] Retirement/Pension E] Dividends, interest. royaltiesI] 2"" job or other income: @ "My Income amounts are stated below. (describe) (a) My monthly net income after taxes are taken out is: (b) The amount i receive each month in public benefits is: am Total income —» 5 fl. 0 0 + Total amount received -+ s (g: Q g) (c) The amount of income from other people in my household is:" + Total amount received —+ 5 4'2 (>0 (d) The amount I receive each month from other sources is: Total amount received —» + s g, 0;") (a) My TOTAL monthly income is = Add all sources of income above—t» *List this income only if other members contribute to your household income. $( .3 I (if? © TexasLawHelp.crg - Affidavit of lndigency, Febmary 2014 Page1 of 2 (5) About my dependents: “The people who depend on me flnancially are listed below: Name Age Relationship to Me 1 2 3 4 5 6 © “My property Includes: Value‘ @"My monthly expenses are: Amount Cash 5 Q Bank accounts, other financial assets (List) ,C)C> Rentlhouse payments/maintenance s C) (510 s O, C"): i Food and household supplies Utilities and telephone s Q aa /) 3 Q €35) ()é) Clothing and laundry M $ 0l , 00 3 £2, 9;"; $ Medical and dental expenses Vehicles (cars, boats) (List make and year) $ Q, Q‘& Insurance (life, health. auto. etc) s C) 00 School and child care 3 Q Qfg if‘. /j() Vehicle payments s C"; 5g) Gas, bus fare, auto repair 0/ (I) 5 /), 06> Real estate (house or land) (Do not list the house you live Child / spousal support s d? O / L1 >7 00 In.) Wages withheld by court order Debt payments s C) (If) (‘2, 043 ' )6.) $ Other property (like jewelry, stocks. etc.) Other expenses (Describe) s f) , (>