Affidavit Of Inability To Pay Court Costs And Ad Litem Fees Form
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2CAUSE NO. PR ________________
IN THE GUARDIANSHIP OF
§
IN PROBATE COURT
_______________________________________,
§
NO. ____ OF
AN INCAPACITATED PERSON
§
DALLAS COUNTY, TEXAS
AFFIDAVIT OF INABILITY TO PAY COURT COSTS AND AD LITEM FEES
STATE OF TEXAS
§
COUNTY OF DALLAS
§
The undersigned appeared before me, a notary public, and after being duly sworn, declared the
following:
“I, ________________________________, (“Applicant”), declare that the Ward named above does not
have sufficient assets and income to pay court costs and ad litem fees in this guardianship proceeding. In
support of such conclusion, I am aware of the following information concerning the Ward:
(Please put N/A by all items that do not apply. When this affidavit is complete, there should be no
blanks. Use a separate sheet if extra space is needed – all income, expense and assets should be listed.)
1.
Ward’s Monthly Income
Social Security Retirement Income
$ __________________
Social Security Survivor Income
$ __________________
Social Security Disability Income (SSDI)
$ __________________
Supplemental Security Income (SSI)
$ __________________
Payments received from Trust Funds
$ __________________
Payments received from Special Needs Trusts
$ __________________
Veteran’s Administration Benefits (VA but not ANA)
$ __________________
IRA (all types) and 401(k) payments
$ __________________
Investment Income and Dividends
$ __________________
Annuity payments
$ __________________
Pensions
$ __________________
Railroad Retirement / Teacher’s Retirement payments
$ __________________
All other Retirement payments
$ __________________
Child Support payments
$ __________________
Oil and Gas Royalties
$ __________________
Other sources of income
________________________________________
$ __________________
TOTAL OF ALL MONTHLY INCOME
$
2.
Does the Ward reside in a nursing home or a facility? Y___ N ___
Does the Ward receive any government assistance to pay for their residential care? Y___ N___
Does the Ward receive Medicaid Benefits?
Y___ N___
Name of Ward’s Representative Payee?
_____________________________________________
Address of Representative Payee: ______________________________________________________________
Affidavit of Inability to Pay (last updated 1/1/2014)
Page 1
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