Childress, Jason ( 2015 )

AFFIDAVIT OF INDIGENCE
CAUSE NO. ____________________
IN THE COURT OF CRIMINAL
APPEALS OF TEXAS
THE STATE OF TEXAS:
COUNTY OF AUSTIN:
The undersigned makes this affidavit in connection with the filing of the above-numbered
and entitled cause without the posting of a security deposit and for the purpose of having citation
issued in accordance with Texas Rule of Civil Procedure 145 and Texas Rule of Appellate
Procedure 20.1. (The items applicable to the undersigned and checked and the information called
for is furnished under penalties of perjury.)
1. Basis for indigence: I am unable to pay a court cost because:
I am presently receiving a government entitlement based on indigence as follows
(describe nature and amount of government entitlement):
Supplemental Nutrition Assistance Program (SNAP) benefits at $194 per month until the
month of October, 2015 and have been approved for assistance under the Workforce
Investment Act.
and
I have no ability to pay court costs based on facts set out below.
2. Employment information:
I am not now employed; the last time I was employed was on March 3, 2015 to March
19, 2015 at Amazon Fulfillment Center, located at 700 Westport Pkwy, Fort Worth, TX
76177. Due to medical reason (pulmonay embolism), I was forced to resign from the
aforementioned employer.
3. Income from sources other than employment:
I have no income which is derived from employment, as I am currently unemployed, no
do I have income which is derived such as interest, dividends, annuities, etc.
4. I am single and have no Income from a Spouse.
1
AFFIDAVIT OF INDIGENCE
5. Property:
I own no property and no interest in any property.
6. Bank Accounts: (statements attached hereto, and incorporated herein)
Bank Type of Account Amount
MB Financial Bank Checking $2.33
7. Dependents:
I have no dependents.
8. Debts:
I have the following debts:
Creditor Amount
John Peter Smith Hospital $42,920.40
9. I have the no monthly expenses. I am currently living with an immediate family member, i.e.,
sister, who pays added electric and water utilities incurred by my presence and living with her.
10. Attorneys: I am not represented by an attorney in this court nor was I represented by an
attorney in the trial court.
I, Jason Childress, Affiant herein, am Indigent and unable to pay the costs of court.
Further, I am unable to provide the required 11 copies pursuant to T.R.A.P. Rule 9.3. (b) (1) and
request that requirement be waived. I verify that the statements made in this affidavit are true and
correct..
Respectfully submited,
/s/: Jason Childress
Affiant,
Jason T. Childress
Signed this the 3rd day of August , 2015.
2
AFFIDAVIT OF INDIGENCE
VERIFICATION
Executed without the United States:
Pursuant to 28 U.S. Code § 1746 (a): I, Jason Truman Childress, Affiant herein, in lieu of
Notarization of this document, due to an inability to pay therefor, do declare, certify, verify
and state under penalty of perjury under the laws of the United States of America that I am a
living man, of lawful age and facts ans statements made herein by me are true and correct.
Executed on this 3rd day of August , 2015.
/s/: Jason Childress
Jason Childress
9141 Gristmill Ct.
Fort Worth, Texas
3
Form TF0001
April2015
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
P O BOX 149029
AUSTIN, TEXAS 7 87 1 4.9A29
l*hTE,\AS
hfr'*HlllruIffi'll*
oate: 06115/2015
Need help?
GaseNumber: 1025563950
Call 2-1 -1 or 1 -877-541 -7905
lf you have a hearing or speech disability,
call 7-1-1 or any relay service.
All numbers are free to call.
JASON CHILDRESS
9141 GRISTMILL CT
FORT WORTH TX 76179.5007
Notice about your case:
SNAP Food Benefite
EDG numtrer:632939553
Who gets SNAP Food Benefits
Name Date Monthlv Amount
Jason Childress 47to1t2015 - 10t31na15 $ 194.00
Page 1 of2 ,937
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JPS Health Network
Eligibility and Enrollment Department
This patient has been approved for JPS Connection plan: JPS connection rier 1 Approved
Name: JASON CHILDRESS Participant #:
Additional Family Members.
Address: 9141 GRISTMILL CT
FORT WORTH TX 76179
Start Date: A4n512CI15 Expiration Date: 0412512016
Eligibility Screenen Jutie
Save
JPS Connection Program Copay
Effective November t, 2014
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JPSC Supplemental
fcrttrri:ij iir fririr Homeless JPSC
nsi Powered by Pride
Copay Copay
to Medicare/lnsurance
Copay
Outpatient Visit
SO Ss Ss
Primarv /Soecialtv Care
Urgent Care $o 5zs 52s
Emerqency Room Visit[x J) SO $zso Szso
ii,ri.: irii:;irj:*+;i.
So $200 Maximum $200 Maximum
lnpatient Hospitalizat,on J$s,
$0 ea add day 5100 ea add day SlOO ea add day
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Colonoscopy and
Mammogram $0 $0 $0
(Preventive/Screen i no)
Physical Therapy $5 $5
$0
Per Visit Per Visit
Radiation Therapy $ro $ro
SO
Chemotherapy Per Visit Per Visit
Lab/Radiology
Other Testingff reatments So So So
Level l& ll
Lab/Radiology Level lll,
Diagnostic Golonoscopy SO Sso Sso
Diagnostic Mammography
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Outpatient Surgery
Cardiac Cath, Angio, l/R
SO Slso Srso
According to Plan
Diabetic Supplies $0 s10
Documents
Prescription Drugs Tier I
According to Plan
generic (Limit 5, 30 day SO $5
Documents
supply)
Prescription Drugs Tier ll
According to Plan
non- generic (Limit 5, 30 day $o $10
Documents
suoolv)
Prescription Drugs Tier lll According to Plan
(Limit 5. 30 dav suoolv) SO $20
Documents
fu,w*t'1fr',J
Executive Director, Revenue
Cycle
Revised 10130/14
a#*q
PO Box 916046 r Fort Worth TX 76191
Telephone: (&M) 2194565
Thank you for choosing JPS Health Network. We hope to continue serving your healthcare needs. All insurance
carriers were billed and have processed your claim" The outstanding balance is now due. lf you have any
questions or concerns about your bill, please contact our Customer Service Department at (844) 21 94565
between the hours of 8:00 am to 5:00 pm.
Thank you in advance for your cooperation and prompt attention to this matter. We look forward to serving you
and your family in the future.
STATEMENT Por{e o -tl;-t I JC,'. _
Summary
Guarantor Name CHILDRESS, JASON FOR BILLING QUESTIONS: Please call
Statement Date 07t17t2015
Account Number 06000{989379 JPS Health Network
Total Patient Responsibility Business Office
42,920.40
Toll Free: (844) 2194565
Payments 0.00 Monday - Friday 8:00 am to 5:00 pm
INSURANCE INFORMATION
Company Name: SELF PAY
Policy Holder: CHILDRESS,JASON
Policy Number:
For your privacy, a portion of the policy number has been
hidden. Please contad us with any changes or corrections.
Nature is important ,.. So is convenience!
To make a payment, update your
information, and more, visit:
wunr.med billoffice.com/ipshn $0.00
use Record Locator#: 3fi16550
Space only permits for a limited number of accounfs. P/ease call our office with any billing questions.
PLEASE SEE REVERSE SIDE FOR IMPORTANT INFORMATION
808CSFPRS03241 000000227
"**Please Detach Lower Portion and Return With Payment***
To make payment online, go to
www.medbil loffice.com/jpshn and
JPS Health Network Business Office use Record Locator # 3436550
PO Box 1660
Greeley CO 80632-1660
ADDRESS SERVICE REQUESTED
SEND ALL PAYMENTS TO:
July 17,2015
JPS Health Network
Business Office
3436550-2410000227 638460225 PO Box 916046
l;lllllrrrlrlrrrllll'lllrrtllt'rr1'llrtlltltll,tt,illlrlu,ltrtll Fort Worth TX 76191-6046
Jason Childress 11,,,1,11,,,,'lll'1,',,,11,11,,11,,,,1,,1,11,',l,,l,ll,,ll,,,l
9141 GristmillCt
Fort Worth TX 76179-5007