No. _____________________

[leave blank; case number will be assigned later]

[insert caption used in appeal, i.e.,

[name of appellant ] v. [name of appellee]]

Affidavit of Indigence

[sample; for use in appeals; file with trial–court clerk

with or before filing notice of appeal]

I, [appellant's name], swear [or affirm] the following:

1. I have filed an appeal in the case described above.

2. I can pay the following amount of court costs in this appeal, which includes the $175 filing fee, the $10 or $15 filing fee for each motion I may file, the trial-clerk's fee for the clerk's record, and the court reporter's fee for the reporter's record, if any: [describe in detail amount, if any, you can pay].

3. The nature and amount of my current employment income is [describe in detail].

4. The nature and amount of my current government-entitlement income is [describe in detail].

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. The income of my spouse is [describe in detail]. My spouse's income [is or is not] available to me.

7. I own the following real property: [describe in detail].

8. I own the following personal property: [describe in detail].

9. I have the following amount of cash: [describe in detail].

10. I have the following amounts of funds on deposit that I may withdraw: [describe in detail].

11. I have the following assets, other than those described in my answers to 3 through 10 above: [describe in detail].

12. I have [provide number] dependants. My relationship to each of them is [describe in detail].

13. The nature and amount of my debts are [describe in detail].

14. The nature and amount of my monthly expenses are [describe in detail].

15. My ability to obtain a loan for court costs is [describe in detail].

16. An attorney [is or is not] providing free legal services to me without a contingent fee.

17. An attorney [has or has not] agreed to pay or advance court costs.

18. [If the trial-court proceedings were recorded electronically] I [have or lack] the skills and access to equipment necessary to prepare the appendix required by Texas Rule of Appellate Procedure 38.5(d).

______________________________________

[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, I administered the above oath or affirmation from the person named above. I am a ____________________________________ and am authorized to administer an oath or affirmation pursuant to Texas Government Code section 602.002, 602.003, 602.004, or 602.005. If I have a seal of office that I am required by law to affix to documents when administering an oath or affirmation, then I have included an original impression of my official seal below.

______________________________________

[Signature of person administering oath or affirmation]

______________________________________

[Date]

[original impression of official seal, if any, of person administering oath or affirmation]