AFFIDA VIr OF INDIGENCY 
This section to be filled out by Court Personnel 
No. 	_ 
The State of Texas vs. 
	In the County Court at Law No. 	_ 
	__ ~~__ 	County 
Offense 	~ __ ~_ 
Level of Offense 	~~ 
			Defendant's Personal Information 				
Name 						
Phone Number 						
Street Address 						
City, State, Zip 						
Social Security # 						
Driver's License # 						
Date of Birth 						
Name of Spouse 						
Dependents: 						
Name(s) (list below) 			Age 	Relation 	Income 	

							
							
Employer Information 						
Employer 						
Phone Number 						
Supervisor's Name 						
Street Address: 						
City, State, Zip 						
Hours worked 	per week or 	per month 				
Pay rate 						
							
Spouse's Employer 						
Street Address: 						
City, State, Zip 						
Hours worked 	per week or 	per month 				
Pay rate 						
							
If unemployed, list: 						
Length of time unemployed 						
Name of previous employer 						
Street Address of previous employer: 					
City, State, Zip 						
		Defendant's Financial Information 				
Public assistance 						
Are you currently receiving (check all that apply) 					
~~ Food Stamps 						
~- 	Medicaid 						
~~ Public housing 						
~_ Temporary Assistance to Needy Families (TANF) 				
~_ Supplemental Security Income (SSI) 					
						EXHIBIT –C1	
" 

EXPENSES(~ONTHLY) 		Monthly 		INCOME (MONTHLY) 	Monthly 	
		Payment 			Amount 	
Rent or Mortgage Payment 						
				Take Home Pay 		
Car Payment 				Spouse's Take Home Pay 		
Insurance (Life, Health, Car, 						
				Investment Income 		
Homeowners, etc.) 				Stock Dividend 		
Child Care 				Bond Dividend 		
Child Support 				Rental Income 		
Water 				Pension Payments 		
Gas 				Unemployment 		
Telephone 						
				Social Security Benefits 		
Electricity 						
				Child Support 		
Food 				Public Assistance 		
Clothes 				TANF 		
Medical 				SSI 		
Cable TV or Satellite TV 				Medicaid 		
Pager 				Other 		
Cell Phone 				Cash Gifts 		
Loan and Debt Payments 				Other (Describe) 		
Outstanding Loans (list type of Loans) 					
						
				TOTAL GROSS 		
Credit Card Debt (list name of cards) 			MONTHLY INCOME 		
$ 	Balance: 					
$ 	Balance: 					
Other Monthly Expenditures (Describe) 					

Assets 					
	Asset 		Value 	
A. Place of Residence 	Rent 	Own 		$ 	
	-- 	-- 			
Describe if house, condominium, apartment, other: 			
B. Real Property Owned; Description/Location: 		$ 	
c. Automobile(s) 					
Make 	Model 		Year 	$ 	
Make 	Model 		Year 	$ 	
D. Bank Accounts 					
Bank Name 			Type of Account 	Balance 	
I have/ have not (circle one) attempted to hire an attorney. The names of the attorneys I have contacted as follows: 
By signing my name below, I swear, that all of the above information about my financial condition is current, accurate, and true. By signing below, I understand that a court official can verify any of the information for accuracy as required to determine my eligibility. 
Defendant's Signature 
	SUBSCRIBED and SWORN to before me, the undersigned authority, this __ day of 	" 20_ 
Signature of Judge 
This court finds the defendant __ is / __ is not indigent. 
Signature of Judge