Statement of Inability to Afford Payment of Court Costs or an Appeal Bond
(JP5 Class C Misdemeanor Violations Only)
Cause Number
*
If unknown, please call JP5 at 512-854-9049
Your Information
Legal Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your mailing address different than your home address?
Yes
No
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dependents
The people who depend on me financially are listed below:
Dependent 1
Full Name
First Name
Last Name
Age
Relationship to Me
Add another dependent?
Yes
No
Dependent 2
Full Name
First Name
Last Name
Age
Relationship to Me
Add another dependent?
Yes
No
Dependent 3
Full Name
First Name
Last Name
Age
Relationship to Me
Add another dependent?
Yes
No
Dependent 4
Full Name
First Name
Last Name
Age
Relationship to Me
Add another dependent?
Yes
No
Dependent 5
Full Name
First Name
Last Name
Age
Relationship to Me
Add another dependent?
Yes
No
Dependent 6
Full Name
First Name
Last Name
Age
Relationship to Me
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Legal Aid Information
Are you represented by Legal Aid?
I am being represented in this case for free by an attorney who works for a legal aid provider or who received my case through a legal aid provider. I have attached the certificate the legal aid provider.
I asked a legal-aid provider to represent me, and the provider determined that I am financially eligible for representation, but the provider could not take my case. I have attached documentation from legal aid stating this.
I am not represented by legal aid. I did not apply for representation by legal aid.
Upload Legal Aid Certificate Proof
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Upload documentation from legal aid
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Public Benefits Information
Do you receive public benefits?
Yes, I do receive public benefits/government entitlements
No, I do not receive needs-based public benefits
I receive the following public benefits/government entitlements that are based on indigency:
Food Stamps/SNAP
TANF
Medicaid
CHIP
SSI
WIC
AABD
Public Housing or Section 8 Housing
Low-Income Energy Assistance
Emergency Assistance
Telephone Lifeline
Community Care via DADS
LIS in Medicare ("Extra Help")
Needs-based VA Pension
Child Care Assistance Under Child Care and Development Block Grant
County Assistance, County Health Care, or General Assistance (GA)
Other
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Monthly Income
Are you currently employed?
*
Yes
No
Your Job Title
Your Employer
I have been unemployed since
/
Month
/
Day
Year
Date
Monthly Household Income Received
Monthly Income Received ($)
Monthly Wages
Unemployment
Public Benefits
Retirement/Pension
Tips, bonuses
Disability
Worker's Compensation
Social Security
Military Housing
Dividends, Interest, Royalties
Child/Spousal Support
My spouse's income or income from another member of my household
Total Monthly Income
Property Value and Assets
Cash
Cash Value ($)
Enter number amount without dollar sign
Bank accounts, other financial assets
Type of Bank Account/Financial Asset
Bank Account/Financial Asset Value ($)
Enter number amount without dollar sign
Add another bank account/financial asset item?
Yes
No
Type of Bank Account/Financial Asset
Bank Account/Financial Asset Value ($)
Enter number amount without dollar sign
Add another bank account/financial asset item?
Yes
No
Type of Bank Account/Financial Asset
Bank Account/Financial Asset Value ($)
Enter number amount without dollar sign
Vehicles (cars, boats)
Type of Vehicle
Model Make & Year
Vehicle Value ($)
Enter number amount without dollar sign
Add another vehicle?
Yes
No
Type of Vehicle
Model Make & Year
Vehicle Value ($)
Enter number amount without dollar sign
Add another vehicle?
Yes
No
Type of Vehicle
Model Make & Year
Vehicle Value ($)
Enter number amount without dollar sign
Other property (like jewelry, stocks, land, another house, etc.)
Other property type
Please Select
Jewelry
Stocks
Land
Another House
Other
Other Property Value ($)
Enter number amount without dollar sign
Add another other property item?
Yes
No
Other property type
Please Select
Jewelry
Stocks
Land
Another House
Other
Other Property Value ($)
Enter number amount without dollar sign
Add another other property item?
Yes
No
Other property type
Please Select
Jewelry
Stocks
Land
Another House
Other
Other Property Value ($)
Enter number amount without dollar sign
Total value of property
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Monthly Expenses and Debts
What are your monthly expenses?
Amount ($)
Rent/house payments/maintenance
Food and household supplies
Utilities and telephone
Clothing and laundry
Medical and dental expenses
Insurance (life, health, auto, etc.)
School and child care
Transportation, auto repair, gas
Child / Spousal support
Wages withheld by court order
Debt payments
Total Monthly Expenses
Are there debts or other facts explaining your financial situation?
List debt and amount owed
If you want the court to consider other facts, such as unusual medical expenses, family emergencies, etc., please upload any additional supporting facts
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Acknowledgement and Declaration
I declare under penalty of perjury that the foregoing is true and correct. I further swear:
*
I cannot afford to pay court costs.
I cannot furnish an appeal bond or pay a cash deposit to appeal a justice court decision.
Name
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Signature
*
Signed On
/
Month
/
Day
Year
Today's Date
Signed on
Signed Date
in
County
County,
State
.
Submit
Should be Empty: