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^^^ (fWvmi/A A!'KM;AV1T(:!' IriUJfJKh'CK , _ __ _. __ ***gfS* H°ysxo ap^al Tim sevtfo/i fit hjJilted mil hy Court IW.w/uiel ., "**'7H^s MAY cAimv.it. _ '8 ?015 CHfHSTn The Slate of Texas In the•__. vs. Bra/otiaCouiily, Texas iVIh _ OlTciise Uoiul:" LevclorOITensc

All information must be completed by the defendant and must be current, accurate, and tr\ic) Intentionally or knowingly giving false information may result in your prosecution for the offense1 jof aggravated perjury, a felony. The punishment for aggravated perjury includes imprisonment' .not to exceed ten (10) years and a fine not to exceed ten thousand dollars (SIO.OOO). Please fill in all' blanks. Ifyou do not know the information being asked, enter DO NOT KNOW in the blank. If ;tiu information being asked docs not apply to you, enter N/A in the blank.

DEFENDANT'S PERSONAL INFORMATION Name J]of\ft£V £3£.\ WWtfrMf -&1<q\74*\ Phone Number Street Address J ^01 C(XLf\Ts./ . (L* A*5 City, State, Zip j) A£.(^fy^ -r^?j 17^^ Social Security.*.j&Xfr .^m Drivers License K-ftfttm-l**?

Name of Spouse Dependents: f\lj, Name(s) (list below): Age Relation Income N/fr

Are you currently in jail or in a correctional institution? xNo j/_ Yes Ifyes, provide name ofinstitution: BraZ-o£\A Coavtf\i ~J3\\ Are vimi currently residing in a mental health facility?

Yes Ifyes, provide name of Facility: Do yojHiave an application pending at a mental health facility? /No Yes If yes, provide name of facility:

•-••!• j.-.«- t- H il I'lHC I i)l 1haw/have nol (circle otic) aUempleJ to hire an attorney. 'I lie nanusof th: attorneys lime contacted are as follows:

M-T- O )i\ this N|i- day of .,20 have been advised by the c 'oiifl of my'right to representaticoi\ bycitttrfsel to defend me as to the diarge(s) pending ai;.ain>t me. I am without means to cinpjpy-tfoiii^el of my own chousiiH^wltfl hereby request th^ctuirl to appoint counsel tor nu\ Resigning my name below, I s\yj>alCthat all of the abovc>fforiuation about my financial condition is current, accurate, autKtrue. I understand thaj/ffl reecivc an appointed attot-n^and make bond, I shall comprywith the additional tern^and conditions of bond imposcd'b)' the Court. I understand thatluiy violation of these conditions may result in my bond being]held insufficient and me bcingreturned to custody.

<L£±- 'li2£c£v^\ DcfcGulantls Signature SUBSCRIBED and SWORN to before me, the undersigned authority, this day of . , 20_ .

BY:

Printed Name Title

RECOMMENDATION: • Indigent • Partially Indigent • Does Not Qualify Verified on by After reviewing this sworn Affidavit of Indigency, I find that this defendant is indigent under the guidelines of Brazoria County and is entitled to appointment of as his attorney, and as additional conditions of bond, defendant shall (I) keep all appointments with the attorney; (2) attend all court settings on time; and (3) notify the attorney or the attorney's office of any changes in his residence address, business address or telephone numbers within twenty-four (2-1) hours of such change.

Defendant's Initials

Date Judge/Court Administrator/Court Designee VERIFICATION AGREEMENT I do /do not (circle one) authorize the court to verify the financial information given to determine my eligibility by contacting my employer and/or other third parties who can confirm the information provided. I understand that if I do not authorize the court to contact the necessary parties, then I must provide verification of the information in a manner that is acceptable to the court or I will not have an attorney appointed. iguaturc SUBSCRIBED and SWORN to before me, the undersigned authority, this day of , 20 BY: Printed Name Title my employment information: Job title: Employer's Name: _ Employer's Address: Supervisor's name: _ Work Phone: Hours of Work: Pay rate: My financial information: Name of Financial Institution: Account number: Balance: Signature of Employee/Person Subject to Financial Information I ! IK VI • \!t:.l >.