Fill and Sign the Affidavit Inability Pay Form

NO. ______________________ IN THE MATTER OF § IN THE DISTRICT COURT THE MARRIAGE OF § §       § AND § _______ JUDICIAL DISTRICT       § § AND IN THE INTEREST OF §       and       , §       COUNTY, TEXAS CHILDREN § § AFFIDAVIT OF INABILITY TO PAY COSTS STATE OF TEXAS § COUNTY OF       § BEFORE ME, the undersigned authority, on this day personally appeared _____________ , who by me being duly sworn, on oath stated: "My income, resources and expenses are set out in the schedule below: MONTHLY INCOME: Amount Source or Description a) Public Benefits: ______________ _______________________ b) Net Employment: ______________ _______________________ c) Other Income: ______________ _______________________ d) Spouse's Income: ______________ _______________________ (if applicable) ______________ _______________________ NUMBER OF DEPENDENTS: ____ PROPERTY: a) Cars or Trucks (Year/Make): 1. _____________________________ 2. _____________________________ b) Checking and/or Savings Account: Bank: _____________________________ Amount: _____________________________ c) Cash: _____________________________ MONTHLY EXPENSES: Rent/Mortgage: _____________ Car Payment: _____________ Transportation: _____________ Insurance: _____________ Clothing/Laundry: _____________ Food: _____________ Child Care: _____________ Medical/Dental: _____________ Utilities: _____________ Other: _____________ TOTAL MONTHLY EXPENSES: _____________ DEBTS AND CHILD SUPPORT OBLIGATIONS (exclude house and automobile): Creditors Monthly Payment 1. __________________ __________________ 2. __________________ __________________ 3. __________________ __________________ 4. __________________ __________________ 5. __________________ __________________ "I am unable to pay the court costs in this cause. I verify that the statements made in this affidavit are true and correct." _______________________________       , AFFIANT SUBSCRIBED AND SWORN TO this __________ day of _________________, ______ . __________________________________ Notary Public, State of Texas