Title: HALE COUNTY, TEXAS
Author: Judge Ed Self
Last saved by: elself
Company: 242nd District Court

THE STATE OF TEXAS			Date:_____________________________

VS.					Charge:___________________________

_____________________			Cause No.:_________________________

AFFIDAVIT OF FINANCIAL STATUS

	The undersigned accused, after being duly sworn, states under oath that the following information regarding his or her financial affairs is true and correct.

1.  Martial status: Single_____Married and living together_____ Married but Separated_____
2.  Dependent children living with you and their ages:
     ___________________________________________________________________________
3.  Your home address:___________________________________________________________                            Street & No.                                             City & State
4.  If employed, name of employer:_________________________________________________
5.  What is your gross (total before deductions) income?___________________per month/week
6.  If you and your spouse are living together, is your spouse employed?____________________
What is your spouse’s  gross (total before deductions) income?_________________per month/week
7.  If you are not employed, how are you supporting yourself?____________________________
8.  What are your monthly expenses:   	Rent/mortgage_______________
Food_______________________		Utilities:____________________
Car payment_________________		Car insurance________________
Car gasoline_________________		___________________________
Other expenses:______________		___________________________

	Under penalties of perjury, I swear or affirm that I have examined the above document and to the best of my knowledge and belief all information shown is true and correct.  I ask the court to appoint an attorney to represent me in this case because I do not have the financial ability to hire my own attorney.  I understand that I may be ordered to make weekly payments to repay the county for such attorney’s fees.

						____________________________________
						Defendant

Subscribed and sworn to before me this _____day of ____________________, 20_______.

						_____________________________________
						Magistrate/ Notary Public