in the Matter of the Marriage of Edsel A. Dixon and Heather D. Dixon, and in the Interest of Ashley Lynn Dixon, a Child, 12-15-00080-CV

in the Matter of the Marriage of Edsel A. Dixon and Heather D. Dixon, and in the Interest of Ashley Lynn Dixon, a Child

12-15-00080-CV

Tex. App.

Apr 9, 2015

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Case Information

12-15-00080-CV

NOTICE: THIS FORM CONTAINS SENSITIVE DATA.

Cause Number: (The Clerk's office will fill in the Cause Number when you fill this form.)

In the (check one): 254 (Court Number) $◻$ District Gourt ATHY S. LUSK, CLERK County Court at Law Justice of the Peace

Respondent/

Defendant

Affidavit of Indigency

(Request to Not Pay Court Fees) Use this form to ask the court not to charge you for court fees. This form is also called an "Affidavit of Inability to Pay Court Costs" or a "Pauper's Oath." You can only use this form if: (1) you get public benefits because you are poor or (2) you can't pay court fees. The information you give on this form must be current, complete, true and correct.

You must either 1) sign this form in front of a notary public or 2) sign this form and sign and attach a completed "Unsworn Declaration" form. By signing in front of a notary, you swear under oath that the information provided is true and correct. By signing and attaching an "Unsworn Declaration" form, you declare under penalty of perjury that the information provided is true and correct.

You can be prosecuted if you lie on this form. The court may or may not approve this request to not pay court fees. The court may order you to answer questions about your finances at a hearing. At that hearing you will have to present evidence to the judge of your income and expenses to prove that you have no ability to pay court fees.

(1) The person who signed this affidavit appeared, in person, before me, the undersigned notary, and stated under oath: "My name is Ede 1 A. Dren My phone number is (682)301-0592 "My mailing address is T32 Waddle Dr. Grapevine, T.V. 76051 "My email address is Edixon 903 (6) 9900011 con "I am above the age of eighteen (18) years, and I am fully competent to make this affidavit. I am unable to pay court costs. The nature and amount of my income, resources, debts, and expenses are described in this form. Check ALL boxes that apply and fill in the blanks describing the amounts and sources of your income. (2) "I receive these public benefits/government entitlements that are based on indigency:

| SSI | $◻$ WIC | $◻$ Food Stamps/SNAP | $◻$ TANF | $◻$ Medicaid | $◻$ CHIP | $◻$ AABD | | :--: | :--: | :--: | :--: | :--: | :--: | :--: | | $◻$ Needs-based VA Pension | $◻$ | County Assistance, County Health Care, or General Assistance (GA) | | | | | | $◻$ LIS in Medicare ("Extra Help") | | $◻$ Community Care via DADS | | Low-Income Energy Assistance | | | | $◻$ Emergency Assistance | | $◻$ Child Care Assistance under Child Care and Development Block Grant | | | | | | $◻$ Public Housing | | Other: (Describe) | | | | |

If you receive any of the above public benefits, attach proof and label it "Exhibit: Proof of Public Benefits" (3) "My income sources are stated below. (Check all that apply) $◻$ Unemployed since: (date) Wages: I work as a Mentersace Tech. for Ealita Petuck Reaity $◻$ Child/spousal support $◻$ My spouse's income or income from another member of my household (if available) $◻$ Tips, bonuses $◻$ Military Housing $◻$ Worker's Comp. $◻$ Disability $◻$ Unemployment $◻$ Social Security $◻$ Retirement/Pension $◻$ Dividends, interest, royalties $◻ 2^{nd}$ job or other income: (4) "My income amounts are stated below. (a) My monthly net income after taxes are taken out is: (b) The amount I receive each month in public benefits is: (c) The amount of income from other people in my household is:* (d) The amount I receive each month from other sources is: (e) My TOTAL monthly income is

Add all sources of income above $\to$

Page 1 of 2

*2 (3) About my dependents: "The people who depend on me financially are listed below: Name

(4) "My debts include: List debt and amount owed. (2)"My monthly expenses are: Amount

To list any other facts you want the court to know, such as unusual medical expenses, family emergencies, etc., attach another page to this form and label it "Exhibit: Additional Supporting Facts." Check here if you attach another page. (10) "I am unable to pay court costs. I verify that the statements made in this affidavit are true and correct." (10) Your Signature. You must either: 1) sign this form in front of a notary public of 2) sign this form and sign and attach a completed "Unsworn Declaration" form.

Your Signitlire State of Texas County of Tayyani Print the name of county where this Affidavit is notarized. Sworn to and subscribed before me today. April $7^{th} 2015$ , by Edel Amas Dixon Print name of person who is signing this Affidavit. NOT the notary's name.

SHILU SHRESTHA NOTARY PUBLIC STATE OF TEXAS MY COMM. EXP. 11/08/17