On August 16, 2021 a
Party Statement
was filed
for Divorce - Children
in the District Court of Smith County.
Preview
NOTICE: THIS DOCUMENT CONTAINS SENSITIVE DATA \-
‘
F
Cause Number: '
gr] l at: I9N” D
( The Clerk‘s ofce in (he Cause Number When you
will'/l l
(Dd P "I l 'éa/Jen,
_,
Plaintiff: I t (check one): .
5r; 66* D D'
_
'
(Pnfirsrand‘lastname'oflhe person linglhefawsuig trict Court
"
E/County‘Court/é‘o‘.
.
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‘
Court M"
:
A
J
»
-‘ Nn.d
I
DJuétice Court
em
I
Number,
Defendantzmok GUI «
_ 5M! *A— '
Texag
my,
. and last name oflhe person being sued.)
(Print rst County
Statement of Inability to Afford Pa'yment _of
Court Costs or an Appeal Bond
i
1. Your Information
My full legal name is: 'Dakr‘f’ " (AIM/e' ga/Jcvn Mil date of birthjs: [23/17
_
Firsr'_ Middl'e Last Month/Day/Yeak
l3"/?8 TX
I
My addressiszrHomg) ado-law Dr. TY/é‘fl‘, 757977
.
FfMai/ing)
My phone nymber: 99.312/6
‘ i233 My email:
About my dependents: “The people who depend on me are listed below.
nancially
Name -
Age Relationshipto Me
wane.» Lame (in/Jen A: 5m
ZISQCIL. (4}th e Co [Jeri g Sm
‘
3 -: '
4'
5.
5
2. Are you represented by Legal Aid?
D l am being represented in this case for free by an attorney who works for a legal aid provideror who
received my case through a legal aid provider. l have attached the certicate the legal aid provider
gave me a's ‘Exhibit: Legal Aid Certicate.
.0r-
D l
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. have attached docdmentation from
‘ 'i
legal aid statingthis. -
1
or-
at
.
represented by legal aid. l did not apply for representation by legal aid.
receive'pu'blic benefits?
ED/oydu
l do not receive needs-based pUblic benefits. - or -
D lreceive these public benefits/government entitlements-that are based on indigencyz' ~
(Check ALL boxes that‘a‘pply' and attach proof to this form, such 'as a copy of an eligibility form or check.)
ood stamps/SNAP D TA'NF
=D Public Housing or Section 8 Housing
D Medicaid _D CHIP
U Low-Income Energy Assistance
D SSl D WlC'
D
D AABD
Emergency Assistance
D Telephone Lifeline D Community Care via DADS D LIS in Medicare ("Extra Help")
U Needs-based VA Pension D Child Care'Assistance under Child Care and Development Block Grant
D County Assistance. County- Health Care, or General Assistance (GA)
U Qther: i
Form Approved by the Supreme Court of Texas by order in Misc. Docket'No. 16-9122 ’
Statement 'o! Inability to Afford Payment of Court Costs
Page 1 of 2
l
‘ .
1
, , . y
i . .
|
.‘
I
4. What'Is yo'ur monthly'tncome‘ and'Income sources?
'l ge't this monthly"Income.
$2g0'0 in mohthl’ywages [work as a 5"&+/7C¥a/1054u
Yourjdb We
'
”erforCMK Sleé'f'M'MK
empla'yer
-You_r
.§ in monthly unemployment. Ihave been unemployed since (date)
§ in public benets per month!
§ from other people"In my hoUsehold each month: (LIsI_ oniyirorher members conIr'I‘buIe Io your
§ , househofdIncome. )
from DRetirement/Pension
D Social Security
U Tips, bonuses
U Military Housing
D Disability D WOrker's Comp
D Dividends, interest royalties
.-
Child/spousal support
D My spouse's income or income from another member of my household
$500 from otherjobslsources ofIncome. (Describe)
Co/lLHm d [Jr/S 6
(travaI'IabIe)
q-VW?“
1.342%"Is my total monthlyIncome.
5. What'Is the value of your property?
"My property includes:
'
-Value*
'
6. What are your
monthly
“My monthly expenses are:
expenses? J
Amount
I
-
Cash ~
|
S“ 20.-
‘
'
Rent/house payments/maintenance $ 0 I
'
Bank; accounts, other financial assets
‘
Food and household supplies . $ €00
madman t . 50. Utilities and teie‘phone
50
'
'-
gab. Cloth'ing and laundry _
s
s 0 '
’
-
Vehicles (cars. boats) (make and year)
s Medical and dental expenses s '0 _
Insurance (life,:health. auto, etc.) Is 60
2.2m
_
”aria? .Dau 5530A 20/7 $ Schooland child c'are s 0 '
$ Transportation] auto repair. gas S Ila
$ Child [spousal support. ‘ S E
Other property (like"jewelry, stocks. land. Wages withheld'by court order
i
another house,etc.)
'
I , -
5‘ O
s
=
”Debt payments paid to: (LisI) 5‘
'
5 .
S
_.‘ $
I
' S
Total value of property L) s .220 30 .50 Total Monthly Expenses
“The ValueIs the amount the item would sell forless th'e amoum you still owe on it ifanything.
—,»s IO 20
~
7. _Are there debts or other
facts explaining your financial situation?
"My debts include: (Listdebtand amount owed) M0awaylé Edvg mwgéo 06 gargm‘lr
02:0
IIIgHI- owe.
_.
"
L I
I
‘I I
(”you want the court Io consider other facts such as unusual medical expenses.
emergencies. etc” attach anotherpage to
Ia'mIIIy
this form labeled Additional Supporting Facts. ")
I‘Exhibii. Check here I'fyou_ attach anotherpage. DI
l8f.Declaration ,
declare under penalty of perjury that the foreg'oing'Is true
cannot afford to pay coUrt costs.
and
correct. l further swear.
D |'cannot furnish an appeal b nd or pay” a 'cash deposit to
appeal a.justice court decision.
My nameis
DON!9g40/9 .
Dr T9/J
.My date of birthis. _Izgl! Z.
MyI
addres's'
IsI 34} Cbcud Tjl 75‘ 7o? 3,5,,64
.
.
SlgnaIure"
I
.
_ .
iIgned on g! ? [-0.21 in
Month/Day/Year
gm, K
State
cpuntynam'e
'
Zip Code
I
‘Qounfy’
If
r
-"
State
Country
‘2': [as
I.
I
I.-
__
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\
I
‘
Form AIpproved'my the Supreme CouIt _oI Texa's by order In Misc. Docket
N_o. 16-9122
Afford
Statement oflnability to of Court Costs I
-
Page 2 of 2
Payment
Document Filed Date
August 16, 2021
Case Filing Date
August 16, 2021
Category
Divorce - Children
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Preview
NOTICE: THIS DOCUMENT CONTAINS SENSITIVE DATA \- ‘ F Cause Number: ' gr] l at: I9N” D ( The Clerk‘s ofce in (he Cause Number When you will'/l l (Dd P "I l 'éa/Jen, _, Plaintiff: I t (check one): . 5r; 66* D D' _ ' (Pnfirsrand‘lastname'oflhe person linglhefawsuig trict Court " E/County‘Court/é‘o‘. . ' ‘ Court M" : A J » -‘ Nn.d I DJuétice Court em I Number, Defendantzmok GUI « _ 5M! *A— ' Texag my, . and last name oflhe person being sued.) (Print rst County Statement of Inability to Afford Pa'yment _of Court Costs or an Appeal Bond i 1. Your Information My full legal name is: 'Dakr‘f’ " (AIM/e' ga/Jcvn Mil date of birthjs: [23/17 _ Firsr'_ Middl'e Last Month/Day/Yeak l3"/?8 TX I My addressiszrHomg) ado-law Dr. TY/é‘fl‘, 757977 . FfMai/ing) My phone nymber: 99.312/6 ‘ i233 My email: About my dependents: “The people who depend on me are listed below. nancially Name - Age Relationshipto Me wane.» Lame (in/Jen A: 5m ZISQCIL. (4}th e Co [Jeri g Sm ‘ 3 -: ' 4' 5. 5 2. Are you represented by Legal Aid? D l am being represented in this case for free by an attorney who works for a legal aid provideror who received my case through a legal aid provider. l have attached the certicate the legal aid provider gave me a's ‘Exhibit: Legal Aid Certicate. .0r- D l 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. have attached docdmentation from ‘ 'i legal aid statingthis. - 1 or- at . represented by legal aid. l did not apply for representation by legal aid. receive'pu'blic benefits? ED/oydu l do not receive needs-based pUblic benefits. - or - D lreceive these public benefits/government entitlements-that are based on indigencyz' ~ (Check ALL boxes that‘a‘pply' and attach proof to this form, such 'as a copy of an eligibility form or check.) ood stamps/SNAP D TA'NF =D Public Housing or Section 8 Housing D Medicaid _D CHIP U Low-Income Energy Assistance D SSl D WlC' D D AABD Emergency Assistance D Telephone Lifeline D Community Care via DADS D LIS in Medicare ("Extra Help") U Needs-based VA Pension D Child Care'Assistance under Child Care and Development Block Grant D County Assistance. County- Health Care, or General Assistance (GA) U Qther: i Form Approved by the Supreme Court of Texas by order in Misc. Docket'No. 16-9122 ’ Statement 'o! Inability to Afford Payment of Court Costs Page 1 of 2 l ‘ . 1 , , . y i . . | .‘ I 4. What'Is yo'ur monthly'tncome‘ and'Income sources? 'l ge't this monthly"Income. $2g0'0 in mohthl’ywages [work as a 5"&+/7C¥a/1054u Yourjdb We ' ”erforCMK Sleé'f'M'MK empla'yer -You_r .§ in monthly unemployment. Ihave been unemployed since (date) § in public benets per month! § from other people"In my hoUsehold each month: (LIsI_ oniyirorher members conIr'I‘buIe Io your § , househofdIncome. ) from DRetirement/Pension D Social Security U Tips, bonuses U Military Housing D Disability D WOrker's Comp D Dividends, interest royalties .- Child/spousal support D My spouse's income or income from another member of my household $500 from otherjobslsources ofIncome. (Describe) Co/lLHm d [Jr/S 6 (travaI'IabIe) q-VW?“ 1.342%"Is my total monthlyIncome. 5. What'Is the value of your property? "My property includes: ' -Value* ' 6. What are your monthly “My monthly expenses are: expenses? J Amount I - Cash ~ | S“ 20.- ‘ ' Rent/house payments/maintenance $ 0 I ' Bank; accounts, other financial assets ‘ Food and household supplies . $ €00 madman t . 50. Utilities and teie‘phone 50 ' '- gab. Cloth'ing and laundry _ s s 0 ' ’ - Vehicles (cars. boats) (make and year) s Medical and dental expenses s '0 _ Insurance (life,:health. auto, etc.) Is 60 2.2m _ ”aria? .Dau 5530A 20/7 $ Schooland child c'are s 0 ' $ Transportation] auto repair. gas S Ila $ Child [spousal support. ‘ S E Other property (like"jewelry, stocks. land. Wages withheld'by court order i another house,etc.) ' I , - 5‘ O s = ”Debt payments paid to: (LisI) 5‘ ' 5 . S _.‘ $ I ' S Total value of property L) s .220 30 .50 Total Monthly Expenses “The ValueIs the amount the item would sell forless th'e amoum you still owe on it ifanything. —,»s IO 20 ~ 7. _Are there debts or other facts explaining your financial situation? "My debts include: (Listdebtand amount owed) M0awaylé Edvg mwgéo 06 gargm‘lr 02:0 IIIgHI- owe. _. " L I I ‘I I (”you want the court Io consider other facts such as unusual medical expenses. emergencies. etc” attach anotherpage to Ia'mIIIy this form labeled Additional Supporting Facts. ") I‘Exhibii. Check here I'fyou_ attach anotherpage. DI l8f.Declaration , declare under penalty of perjury that the foreg'oing'Is true cannot afford to pay coUrt costs. and correct. l further swear. D |'cannot furnish an appeal b nd or pay” a 'cash deposit to appeal a.justice court decision. My nameis DON!9g40/9 . Dr T9/J .My date of birthis. _Izgl! Z. MyI addres's' IsI 34} Cbcud Tjl 75‘ 7o? 3,5,,64 . . SlgnaIure" I . _ . iIgned on g! ? [-0.21 in Month/Day/Year gm, K State cpuntynam'e ' Zip Code I ‘Qounfy’ If r -" State Country ‘2': [as I. I I.- __ I - \ I ‘ Form AIpproved'my the Supreme CouIt _oI Texa's by order In Misc. Docket N_o. 16-9122 Afford Statement oflnability to of Court Costs I - Page 2 of 2 Payment