On November 13, 2019 a
Party Statement
was filed
involving a dispute between
Queen, Matthew Bryan,
and
Queen, Leann Nicole,
for Modification - Other
in the District Court of Smith County.
Preview
NOTlCE: THIS DOCUMENT CONTAINS SENSITIVE DATA ‘ _
W ‘.
L
Cause Number: \Q ‘Ilfi \l’D E
(The 'Clen’x's office m
will filitheCause Number when yo‘u file this form)‘
the
Plaintiff:
and iast name of the pers
(Pn'n! first
m2
filing the lawsuit.)
In
End.
{cher'one).
District05W: ”-
x),
.,
3
33%.}
‘
And
Coufl
Number
D County Court] County Court at, Lraw
shoe Court
fl fl 2m
.
Defendant:
{P:intl
\y
firstand
5W SQ
name
last
\S Qg 5$1
ofthe pelson being sued. )
vmfi\
County
flk Texas
"
“““““““
Statement of Inability to Afford Payment of
Court Costs or an Appea! Bond
1. Your Information
My full legal name is: \“Qmm N K 0m L&WW My date of birth Is:i ml—MU
My addressis: (Home)
First
“.0 m1
SaM/{j
m Middle
qqm LTA ham TY 161’1\
Month/Day/Year
Myphonemmmmmmuguyemau-w
(Mailing)
About my dependents: “The people who depend on me financially are listed below.
Name Age Relationship to Me
son
1
2 mm ,
J
w! 01
sow
WA
L1
s woun (BMW 6 601A,
467mm \
6
'
Are you represented by Legal Aid?
-
2.
[:1 lam 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.
nor-
lasked a legal—aid provider to represent me, and the provider determined that Iam financially eligible
for representation, but the provider could not take my case. Ihave attached documentation from
legal aid stating this.
or-
fim not represented by legal aid. ldid not apply for representation by legal aid.
3. Do you receive public benefits?
D |do not receive needs—based public benefits. —or -
D Ireceive these
(CheckAL L
public
boxes
benefitslgovemment
and
that apply
entitlements that are based on indigency:
s form, such as a co
attach proof ioi of an form or check.)
eiigib'h‘ty
y
m Food stamps/SNAP D TANF Medicaid [ CHIP p
SSI [j WlC D AABD
D- Public Housing or Section 8 Housing D Low-Income Energy Assistance D Emergency Assistance
D Telephone Lifeline Community Care via DADS D LIS in Medicare ("Exfra Help”)
.
D Needs-based VA Pension Child Care Assistance under Child Care and Development BloCk Grant
D County Assistance, County Eealth Care, or General Assistance (GA)
D Other.
© Form Approved by the Supreme Court of Texas by order in Misc. Docket No.
16—9122
Statement of Inability
toAfiord Payment of Court Costs Page 1of 2
4. What isyour monthly income and income sources?
"I
get this monthly income:
$ in monthly wages. |work as a for
Yourjob {it/e Your employer
fi in monthly unemployment. lhave been unemployed since (date)
§ in public benefits per month.
§ from other people inmy household each month: other
(List onlyif members contribute to your
household income.)
§k0\ g from D Retirement/Pension [:1 Tips, bonuses 1:] Disability E] Worker’s Comp
l; Social Security [:1 Military Housing E] Dividends, interest, royalties
Child/spousal support
D My spouse's income or income from another member of my household (Ifavai/ab/e)
$ from otherjobs/sources of income. (Describe)
$ ismy total monthly income.
5.What is the value of your property? 6. What are your monthly expenses?
“My property includes: Va ue* “My monthly expenses are: Afnount
Cash Rent/house payments/maintenanée
$ $ HM)”
Bank accounts, other financial assets Food and household supplies $ 50 l2
and telephone
Utilities $ g! 20
.$ Clothing and laundry $ ()5
| 2
$ Medical a'nd dental expenses $ 2)
Vehicles (cars, boats) (make and year) Insurance (life,health, auto, etc.)
'
$ 5
\b School and care
$
S
child
Transportation, auto repair, .gas
I
FEEL
$
-
$ Child /spousal support
Other property (like jewelry, stocks, land, Wages withheld by coun order
another house. etc.)
$
$
$
CD
l
Debt payments paid to: (List)
M;
Total value of property
*The vazueistheamount the item would
—> $ "‘
the
sell for less amount you owe on
still
TotaIMonthly Expenses
if
it, anything.
—» $ l
Are there debts or other facts explaining your financial situation?
7.
"My debts include:
«cvaeoi/H cmmg
(List demand amount owed)
mono! cow
wm+
gym! 000
lwflhg
:wm
— $%,ODO
cm“ gab,
, \OMHCJ
poo:
Q\O¥ODOI
{lfyou want the court to consider other facts, such as unusual medical expenses, family emergencies, eta, attach another page to
{his Check here ifyou attach another page.[]
form [abated "Exhibit: Additiona/ Supporting Facts. ”)
8. Declaration
l eclare under penalty of perjury that the foregoing istrue and correct. | further swear:
1
_-j|cannot afford to pay court costs.
L] Icannot furnish an appeal bond or pay a cash deposit to appeal a justice court decision.
My nameis
My addressis
bemm
“mq/m
QWV‘
M Mflm
.
TX
My date of birthis
“\‘o’m
:
i I(E/flg;
SMH’VI
WRWM
Sigfl’ature
®WStreet
signedon WI")
City
IM
Month/Day/Year
in SMW
State
couniyname
ZipCode
County,
'
S.
Sta e
Country
E 52:“
© Form Approved by the Supreme Court of Texas by order
inMisc. Docket No. 16-9122
Statement of Inabirity to Afi'ord Payment of Court Costs Page 2 of2
Document Filed Date
December 03, 2019
Case Filing Date
November 13, 2019
Category
Modification - Other
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Preview
NOTlCE: THIS DOCUMENT CONTAINS SENSITIVE DATA ‘ _ W ‘. L Cause Number: \Q ‘Ilfi \l’D E (The 'Clen’x's office m will filitheCause Number when yo‘u file this form)‘ the Plaintiff: and iast name of the pers (Pn'n! first m2 filing the lawsuit.) In End. {cher'one). District05W: ”- x), ., 3 33%.} ‘ And Coufl Number D County Court] County Court at, Lraw shoe Court fl fl 2m . Defendant: {P:intl \y firstand 5W SQ name last \S Qg 5$1 ofthe pelson being sued. ) vmfi\ County flk Texas " “““““““ Statement of Inability to Afford Payment of Court Costs or an Appea! Bond 1. Your Information My full legal name is: \“Qmm N K 0m L&WW My date of birth Is:i ml—MU My addressis: (Home) First “.0 m1 SaM/{j m Middle qqm LTA ham TY 161’1\ Month/Day/Year Myphonemmmmmmuguyemau-w (Mailing) About my dependents: “The people who depend on me financially are listed below. Name Age Relationship to Me son 1 2 mm , J w! 01 sow WA L1 s woun (BMW 6 601A, 467mm \ 6 ' Are you represented by Legal Aid? - 2. [:1 lam 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. nor- lasked a legal—aid provider to represent me, and the provider determined that Iam financially eligible for representation, but the provider could not take my case. Ihave attached documentation from legal aid stating this. or- fim not represented by legal aid. ldid not apply for representation by legal aid. 3. Do you receive public benefits? D |do not receive needs—based public benefits. —or - D Ireceive these (CheckAL L public boxes benefitslgovemment and that apply entitlements that are based on indigency: s form, such as a co attach proof ioi of an form or check.) eiigib'h‘ty y m Food stamps/SNAP D TANF Medicaid [ CHIP p SSI [j WlC D AABD D- Public Housing or Section 8 Housing D Low-Income Energy Assistance D Emergency Assistance D Telephone Lifeline Community Care via DADS D LIS in Medicare ("Exfra Help”) . D Needs-based VA Pension Child Care Assistance under Child Care and Development BloCk Grant D County Assistance, County Eealth Care, or General Assistance (GA) D Other. © Form Approved by the Supreme Court of Texas by order in Misc. Docket No. 16—9122 Statement of Inability toAfiord Payment of Court Costs Page 1of 2 4. What isyour monthly income and income sources? "I get this monthly income: $ in monthly wages. |work as a for Yourjob {it/e Your employer fi in monthly unemployment. lhave been unemployed since (date) § in public benefits per month. § from other people inmy household each month: other (List onlyif members contribute to your household income.) §k0\ g from D Retirement/Pension [:1 Tips, bonuses 1:] Disability E] Worker’s Comp l; Social Security [:1 Military Housing E] Dividends, interest, royalties Child/spousal support D My spouse's income or income from another member of my household (Ifavai/ab/e) $ from otherjobs/sources of income. (Describe) $ ismy total monthly income. 5.What is the value of your property? 6. What are your monthly expenses? “My property includes: Va ue* “My monthly expenses are: Afnount Cash Rent/house payments/maintenanée $ $ HM)” Bank accounts, other financial assets Food and household supplies $ 50 l2 and telephone Utilities $ g! 20 .$ Clothing and laundry $ ()5 | 2 $ Medical a'nd dental expenses $ 2) Vehicles (cars, boats) (make and year) Insurance (life,health, auto, etc.) ' $ 5 \b School and care $ S child Transportation, auto repair, .gas I FEEL $ - $ Child /spousal support Other property (like jewelry, stocks, land, Wages withheld by coun order another house. etc.) $ $ $ CD l Debt payments paid to: (List) M; Total value of property *The vazueistheamount the item would —> $ "‘ the sell for less amount you owe on still TotaIMonthly Expenses if it, anything. —» $ l Are there debts or other facts explaining your financial situation? 7. "My debts include: «cvaeoi/H cmmg (List demand amount owed) mono! cow wm+ gym! 000 lwflhg :wm — $%,ODO cm“ gab, , \OMHCJ poo: Q\O¥ODOI {lfyou want the court to consider other facts, such as unusual medical expenses, family emergencies, eta, attach another page to {his Check here ifyou attach another page.[] form [abated "Exhibit: Additiona/ Supporting Facts. ”) 8. Declaration l eclare under penalty of perjury that the foregoing istrue and correct. | further swear: 1 _-j|cannot afford to pay court costs. L] Icannot furnish an appeal bond or pay a cash deposit to appeal a justice court decision. My nameis My addressis bemm “mq/m QWV‘ M Mflm . TX My date of birthis “\‘o’m : i I(E/flg; SMH’VI WRWM Sigfl’ature ®WStreet signedon WI") City IM Month/Day/Year in SMW State couniyname ZipCode County, ' S. Sta e Country E 52:“ © Form Approved by the Supreme Court of Texas by order inMisc. Docket No. 16-9122 Statement of Inabirity to Afi'ord Payment of Court Costs Page 2 of2