Form Rrp-12 - Fee Affidavit Form printable pdf download

Form Rrp-12 - Fee Affidavit Form

FEE AFFIDAVIT FORM

Original

Supplemental

CLIENT:

PIA/TDCJ #:

S.I.D. #:

ATTORNEY INFORMATION:

MR./MS.

FIRST NAME

MIDDLE

LAST NAME

SUFFIX

ADDRESS

TEXAS BAR NO.

NAME OF BUSINESS

BUSINESS ADDRESS

BUSINESS PHONE #

CITY

STATE

ZIP

BUSINESS FAX #

BCJ-BPP-TDCJ (FORMER OR CURRENT) EMPLOYEE(S) OR MEMBERS WITH WHICH ATTORNEY IS

ASSOCIATED OR HAS A RELATIONSHIP AS AN EMPLOYER OR EMPLOYEE OR MAINTAINS A CONTRACTUAL

RELATIONSHIP TO PROVIDE SERVICES (LIST ADDITIONAL NAMES ON BACK).

FIRST NAME:

MIDDLE:

LAST NAME:

RELATIONSHIP:

ENTITY:

HAVE YOU REGISTERED WITH THE TDCJ-PAROLE DIVISION WITHIN THE LAST 12 MONTHS?

YES/NO

. G

. C

§§ 508.084 and 508.085 require certain information relative to fees, or lack thereof. This affidavit must be

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completed in regards to the relevant areas, signed, sworn and subscribed to before a Notary Public prior to any representation.

NO FEE

I, OR ANY CORPORATION OR FIRM WITH WHICH I AM AFFILIATED, HAVE RECEIVED NO FEE NOR PROMISE

OF FEE FOR SERVICES OF ANY NATURE RENDERED, OR TO BE RENDERED, IN CONNECTION WITH PAROLE

OR EXECUTIVE CLEMENCY FOR THE ABOVE NAMED PERSON.

Signature

Printed Name

II.

COMPENSATED REPRESENTATION

TEXAS GOVERNMENT CODE § 305.002 DEFINES "COMPENSATION" AS MEANING MONEY, SERVICE, FACILITY,

OR OTHER THING OF VALUE OR FINANCIAL BENEFIT THAT IS RECEIVED OR IS TO BE RECEIVED IN RETURN

FOR OR IN CONNECTION WITH SERVICES RENDERED OR TO BE RENDERED.

. G

. C

§ 508.083 mandates that only an Attorney, licensed in the State of Texas, may receive compensation for

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representing an offender subject to the jurisdiction of the Texas Department of Criminal Justice.

AMOUNT OF COMPENSATION RECEIVED OR EXPECTED:

THE PERSON MAKING THE COMPENSATION:

FIRST NAME

MIDDLE

LAST NAME

ADDRESS

PHONE #:

STREET ADDRESS

CITY

STATE

ZIP

I HEREBY SWEAR OR AFFIRM THAT THE ABOVE INFORMATION IS TRUE AND CORRECT, AND

FURTHERMORE, I HEREBY AGREE TO IMMEDIATELY SUPPLEMENT THIS AFFIDAVIT IF ANY OF THE

STATEMENTS MADE HEREIN ARE AFFECTED BY A CHANGE IN FEE AGREEMENT, OR ARRANGEMENT, OR

FACTUAL CONDITIONS.

SIGNATURE

DATE

SWORN TO AND SUBSCRIBED BEFORE ME, THE UNDERSIGNED AUTHORITY, UNDER PENALTY OF PERJURY,

ON THIS THE

DAY OF

, A.D. 20

(SEAL)

SIGNATURE OF HEARING OFFICER OR

NOTARY PUBLIC IN AND FOR THE STATE OF TEXAS

RRP-12 Rev. 10/09

Form Rrp-12 - Fee Affidavit Form

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