Defendant'S Pauper'S Affidavit For Appeal Form - Texas Page 2

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MONTHLY   E XPENSES  
Rent   ( tenant   p ortion):_______________________  
Food: _________________________________________  
Car   P ayment:_________________________________  
Child   C are/Support: ________________________  
Transportation:______________________________  
Medical/Dental:   ____________________________  
Insurance: ____________________________________  
Utilities:______________________________________  
 
_
Clothing/Laundry:___________________________  
Appliance/Furniture:_______________________  
 
DEBTS   ( Total   O wed)  
Child   S upport:   _______________________________  
Other: ________________________________________  
 
_
Credit   C ard: __________________________________  
Other:  
_____________________________________  
 
Payday   L oan:_________________________________  
Other:  
_____________________________________  
 
 
DEPENDENTS  
 
Age  
 
 
Residential   A ddress  
Spouse  
 
 
_________  
 
________________________________________________  
Child   1  
 
 
_________  
 
________________________________________________  
Child   2  
 
 
_________  
 
________________________________________________  
Child   3  
 
 
_________  
 
________________________________________________  
Child   4  
 
 
_________  
 
________________________________________________  
Other    
 
 
_________  
 
________________________________________________  
 
I   a m   u nable   t o   p ay   a ny   p art   o f   t he   c osts   o f   a ppeal,   f ile   a n   a ppeal   b ond,   o r   g ive   s ecurity   f or  
appeal   b ecause   o f   m y   f inancial   c ondition.   I   v erify   t hat   t he   s tatements   m ade   i n   t his   a ffidavit  
are   t rue   a nd   c orrect.”  
 
 
 
 
 
 
____________________________________  
 
 
 
 
 
 
Signature    
 
 
 
 
 
 
 
____________________________________  
 
 
 
 
 
 
Printed   N ame  
 
 
 
 
 
 
 
____________________________________  
 
 
 
 
 
 
Address  
 
 
 
 
 
 
 
____________________________________  
 
 
 
 
 
 
Phone   N umber   ( Daytime)  
 
SUBSCRIBED   A ND   S WORN   T O   B EFORE   m e   o n   t his   _ _______   d ay   o f   _ _________________,   2 0________.  
 
 
 
 
 
 
 
________________________________________________________  
 
 
 
 
 
 
NOTARY   P UBLIC   f or   t he   S tate   o f   T exas  
2   o f   2  

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