Walter Francisco Salinas v. Patricia Melton ( 2015 )

FILED lN
\ST couat oF APPEALS
HQUSTO!‘ ``\'EX 05
DEC -7 2015
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[leave blanl<; case number will be assigned later]
[insert caption used in appeal i..e,
[name of appellant] v. [name of appellee]]
M /////f /a///‘?//‘f //5 /Mvd/JH/W%Q/ cary
Affidavit of lndigence
[sample; for use in appeals; file with trial-court clerk
with or before filing notice of appea|]
//fQ/f?&§
l, [appellant’s name], swear [or affirm] the following: M,,_``
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\
1. l have filed an appeal in the case described above.
Tc@n )70/`` _ _ _ _
2.i-l~aan pay the following amount of court costs in this appeal, which
includes the $175 filing fee, the $‘l 0 or $15 filing fee for each motion l may file,
the trial-clerk’s fee for the clerk’s record, and the Court reporter’s fee for the
reporter’s record1 if any: [describe in detail amount, if any, you can pay].
3. The nature and amount of my current employment income is
[describe in detai|]l ,
4. The nature and amount of my current government”entitlement income
is [describe in detai|]£1 ~755’/;.{/” /14//»'¢!~
5. The nature and amount of my current income, other than that
described in my answers to 3 and 4 above, is [describe in detail]. ///
6. T e income of my spouse is [describe in detail]. lVly spouse's income
[is o@ available to me.
7. l own the following real property: [describe in detai|]. /{/7//£
8. l own the following personal property: [describe in detail]./V///E
9. l have the following amount of cash: [describe in detail]./@/J
10. l have the following amounts of funds on deposit that l may
withdraw: [describe in detail]. ,g/
11. l have the following assets, other than those described in my
answers to 3 through 10 above: [describe in detail].,Q/'
12. l have [provide number] dependants. lVly relationship to each of
them is [describe in detail]. 3
13. The nature and amount of my debts are [describe in detail]. @/
14. The nature and amount of my monthly xpenses are [describe i
deming/953 WW+ //%M/Z@ MQ/a/r§?/@A “/??a¢W¢a/a,,§ao
15. iviy ability to obtain a ioan for court costs is [describe in detail]. [/y//a/
16. An attorney [is or is not] providing free legal services to me without a
contingent fee.
17. An attorney [has or‘agreed to pay or advance court costs.
18. [lf the trial-court proceedings were recorded electronicallyg or
lack] the skills and access to equipment necessary to prepare the appendix
required by Texas Ru|e of Appe|late Procedure 38.5(d).
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[Signature of party claiming indigence, who is
swearing or affirming information given above;
must be signed in presence of person described
below]
Certificate of Oath or Affirmation
On this date, l administere he bo e ath or ffir tio 0
person named above. l ama W&¢%: %YW
and am authorized to administer an oath or affirmation pursuant to Texas
Government Code section 602.002, 602.003, 602.004, or 602.005. lfl have a
seal of office that l am required by law to affix to documents when
administering an oath or aermation, then l have included an original
impression of my ochial seal below.
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