Walter Francisco Salinas v. Patricia Melton
01-15-00702-CV
Tex. App.
Dec 7, 2015
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Case Information

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No. 01-15-00700001

[leave blank; case number will be assigned later] [insert caption used in appeal, i.e., [name of appellant ] v. [name of appellee]] not herf salines 165 Hathcun thon tholon 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: 1611017 Sihros

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

Tcan not 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] 17 - 33 per month. 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]. 101018 8. I own the following personal property: [describe in detail]. 101016 9. I have the following amount of cash: [describe in detail]. 17 10. I have the following amounts of funds on deposit that I may withdraw: [describe in detail].

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  1. I have the following assets, other than those described in my answers to 3 through 10 above: [describe in detail]. Θ
  2. I have [provide number] dependants. My relationship to each of them is [describe in detail]. 3
  3. The nature and amount of my debts are [describe in detail]. Θ
  4. The nature and amount of my monthly expenses are [describe in detail] 4,150 Rant 11/11/20 (Ridert/20 Rengortate/2000
  5. My ability to obtain a loan for court costs is [describe in detail]. 110/11
  6. An attorney [is or is not] providing free legal services to me without a contingent fee.
  7. An attorney [has or has not] agreed to pay or advance court costs.
  8. [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.

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