/-# /3~- O0i>Z*C\J FILED IN 14th COURT OF APPEALS NOTICE: THIS FORM CONTAINS SENSITIVE DATA. HOUSTON TEXAS Cause Number: (The Clerk's office will fill in the Cause Number when you file tf s form. }JAN 28 2015 In the (check one): CHRISTOPHER A. PRINE Petitioner/ Plaintiff D District Cou t CLERK (Court Number) D CountyCourt at Law Q Justice of the Peace Respondent/ ^Df^ /U\r\ V W^7 (&^ County, Texas Defendant J^ryt^f f AvrWL C^^ ^Z^l^^c^CI '(County) I Affidavit of Indigency (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 ofperjurythat the information ability to pay court fees. provided is true and correct. (D The person who signed this affidavit appeared, in person, before me, the undersigned notary, and stated under oath: ^~ *^T "My name is "1^ , ). Jf?>u6^ My phone number is ( J3X )#°fh T£.j*y "My mailing address is ^TwX^ ^Icv^"? T^vff, 4-t~7\" 14th r .~~Hf ~7~76 1LC) "My email address is m £TVt.« A <S i>faAviO i C^yy^) "I am abovethe age ofeighteen (18) years, and I am fully competent to make thisaffidavit. Iam 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 andfill in the blanks describing the amounts and sources of yourincome. © "I receive these public benefits/government entitlements thatare based on indigency: DSSI DWIC • Food Stamps/SNAP D TANF [.Medicaid • CHIP • AABD • Needs-based VA Pension Q County Assistance, County Health Care, orGeneral Assistance (GA) 0"LIS in Medicare ("Extra Help") D Community Care.via DADS EfLow-lncome Energy Assistance • Emergency Assistance • Child Care Assistance under Child Care and Development Block Grant • Public Housing • Other: (Describe) Ifyou receive any of the above public benefits, attach proof and label it "Exhibit: Proofof Public Benefits" ® "My income sources are stated state below. (Check an that apply) D Unemployed since: (date) -or- • Wages: I work as a for Yourjob title Your employer • Child/spousal support Q My spouse's income orincome from another member ofmy household (if available) • Tips, bonuses • Military Housing D Worker's Comp • Disability Q Unemployment )lovment Q _l Social Security, D Retirement/Pension _ Dividends, interest, royalties Q 2nd jobor otherincome © "My income amounts are stated below. ^^_aM//* (describe) (a) My monthly net income aftertaxes are taken out is: Total income after taxes -> 3^ (b) The amount I receive each month in public benefits is: Total amount received -> (c) The amount of incomefrom other people in my household is:* Total amount received ~> (d) The amount I receive each month from other sources is: Total amount received -* (e) My TOTAL monthly income is Add all sources ofincome above-* *Listthis income only if other members contributeto your household income.

Page 1 of 2 © TexasLawHelp.org - Affidavit of Indigency, February 2014 ® About my dependents: "The people who depend on me financially are listed below: Name Age Relationship to Me

© "My property includes: Value* ©"Mymonthly expenses are: Cash _3__, Rent/house payments/maintenance Bank accounts.jother financial assets (Listt Food and household supplies $A*\ §_Z Utilities and telephone Clothing and laundry r*- ayear) Vehicles (qars; boats) (ystmake apdyear) S^* Medical and dental expenses Insurance (life, health, auto, etc) School and child care Vehicle payments Gas, bus fare, auto repair Child / spousal support JS.

Real estate (house or land) (Do not list the house you live in.) Wages withheld by court order 0 \ /A,' o CT f-™ ^J2— Debt payments Other expenses (Describe) Other property (likejewelry, stocks, etc.) (Describe) i d Total value of property -> =$ ^/4/ ^ Total monthly Expenses "The value is the amountthe item would sellfor less the amountyoustill owe on it(ifanything). =$/$&** "* "My debts include: List debt and amount owed. ft j/kXT ^Jb&D V^^ P/wiL^o Y^e<J^ ? Drtrf?$>*P To list any other facts you want the courtto know, such as unusualmedical expenses, family emergencies, etc., attach another page to thisform and labelit "Exhibit: Additional Supporting Facts." Checkhere ifyou attach another page._ ® "I am unable to pay court costs. I verify that the statements made in this affidavit are true and correct." Your Signature. You must either: 1) sign thisform in front of a notary public or 2) sign this forrh\ajxfsign andattach a completed "Unsworn Declaration" form.

W^^U>f^ Date te Notary fills out this section if you state of Texas County of 'eJLlU? are signing in front ofa notary.

Mlj^p? &^^ry^mp)herflate'of N Texas Print the name of county where this Affidavit is notarized. •es Keo7 <\n /y^ " _=_g_T- ^_^emt<rsi NgvemfcpKi o, 20 6 Sworn to and subscnbed_b_efore me teda Date Print name of person whois ofoerson who is signingthisAffidavit sianina this Affidav NOT the notary's name.

Page 2 of 2 © TexasLawHelp.org - Affidavit of Indigency, February 2014 Your New Benefit Amount 6595959

BENEFICIARY'S NAME: TOM J JONES

Your Social Security benefits will increase by 1.7 percent in2015 because ofa rise inthe cost of living. You can use this letter when you need proofofyour benefit amount to receive food, rent, or energy assistance; bank loans; or for other business. Keep this letter with your important financial records.

How Much Will T Get And When? • Your monthly amount (before deductions) is $494.90, • The amount we deduct for Medicare medical insurance is $104.90. (If you did not have Medicare as ofNov. 20,2014, or if someone else pays your premium, we show $0.00.) • The amount we deduct foryourMedicare prescription drug planis $0.00. (If you didnotelect withholding as of Nov. 1,2014,we show $0.00.) • The amount we deduct for voluntary Federal tax withholding is $0-00. (If you did not electvoluntary tax withholding as of Nov. 20,2014, we show $0.00.) • After we take any otherdeductions, you will receive $390,00 on or about Jan. 2, 2015.

If you disagree with any ofthese amounts, you must write tous within 60 days from the date youreceive this letter. We would be happy to review the amounts.

You may receive your benefits through direct deposit, a Direct Express® card, oran Electronic Transfer Account. Ifyou still receive a paper check and want to switch toanelectronic payment, please visit the Department ofthe Treasury's Go Direct website at www.godirectorg.

What If I Have Questions?

Please visit our website atmvw.socialsecurity.gov for more information and a variety ofonline services. You also can call 1-800-772-1213 and speak to a representative from 7 a.m. until 7 p.m., Monday through Friday. Recorded information and services are available 24 hours a day. Our lines are busiest early in the week, early in the month, as well as during the week between Christmas and New Year's Day; itis best to call atother times. Ifyou are deafor hard ofhearing, call ourTTY number, 1-800-325-0778. Ifyou are outside the United States, you can contact any U.S. embassy orconsulate office. Please have your Social Security claim number available when you call orvisit and include iton any letter you send to Social Security. Ifyou are inside the United States and need assistance ofany kind, youcanvisit your local office.

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