Cause Number: Je 11-01577

A plea must be on file with this court. This Court does not accept requests for changes or modifications to payment plans by phone. Please put your request in writing, be specific about what you are seeking and submit your request to the Court along with a statement of inability to pay costs.

The address of the Court is: Judge Katy Hubener 841 W. Irving Blvd. Irving TX 75060

The fax number is: 214-589-7048

Once received, the Judge will review the application and request and send an order either denying or granting the request to you at the address on file.

Judge Katy Hubener Justice of the Peace 4-2 Dallas County, Texas 841 West Irving Boulevard Irving, TX 75060 P. (214) 589-7000 F. (214) 589-7048 CAUSE NUMBER: ______L THE STATE OF TEXAS § IN THE JUSTICE COURT § § VS. § PRECINCT 4, PLACE 2 § § ______§ DEFENDANT § DALLAS COUNTY, TEXAS

DECLARATION OF FINANCIAL INABILITY TO POST BOND OR PAY FINE IN CLASS C MISDEMEANOR CASE

I am the Defendant in the above–styled cause. I am not represented by counsel in this proceeding. I verify that the statements made in this affidavit are true and correct, and contain complete information as to the my identity, the nature and amount of governmental entitlement income, the nature and amount of employment income, other income, (interest, dividends, etc.), spouse's income if available to me, property owned (other than homestead), cash or checking account, dependents, debts, and monthly expenses. I have no assets except the following.

DEFENDANT’S IDENTITY

Defendant’s Full Name

Defendant’s Street Address, City, State, Zip Code

Tenant’s Primary Phone Defendant’s Secondary Phone

Defendant’s Date of Birth

SPOUSE’S IDENTITY

Spouse’s Full Name

Spouse’s Street Address, City, State, Zip Code

Spouse’s Primary Phone Spouse’s Secondary Phone

Spouse’s Date of Birth

DEPENDANTS

Number of Dependants Ages of Dependants

Residence of Dependants Address, City, State, Zip Code

Judge Katy Hubener Justice of the Peace 4-2 Dallas County, Texas 841 West Irving Boulevard Irving, TX 75060 P. (214) 589-7000 F. (214) 589-7048 INCOME OF TENANT & SPOUSE

Tenant’s Employer Tenant’s Job Title and/or Duties

Tenant’s Employer Address, City, State, Zip Code

Tenant’s Supervisor’s Name Tenant’s Supervisor’s Phone

Tenant’s Monthly Salary/Income Tenant’s Other Income

Spouse’s Employer Spouse’s Job Title and/or Duties

Spouse’s Employer Address, City, State, Zip Code

Spouse’s Supervisor’s Name Spouse’s Supervisor’s Phone

Spouse’s Monthly Salary/Income Spouse’s Other Income

GOVERNMENT ENTITLEMENT INCOME

Unemployment Benefits AFDC/TANF

Social Security Disability

Veteran’s Benefits Child Support

Other Amounts - Describe

ALL OTHER INCOME

List all other sources of income and amounts. Cash on hand

Financial Institution of Checking Account Balance Amount

Financial Institution of Savings Account Balance Amount

REAL PROPERTY (residential, commercial, or land owned)

Address of Real Property Owned Value of Property

Judge Katy Hubener Justice of the Peace 4-2 Dallas County, Texas 841 West Irving Boulevard Irving, TX 75060 P. (214) 589-7000 F. (214) 589-7048 PERSONAL PROPERTY (other than household furnishings, clothes, tools of a trade, or personal effects. This includes vehicles and other sources of transportation)

Description of Property Owned Value of Property

MONTHLY EXPENSES

Rent and/or MortgageAmount Vehicle/Car Payment Amount

Insurance Amount Utility Amount

Child Care Amount Child Support Amount

Food and/or Incidental Amount Medical and/or Dental Amount

Other Amount Describe Other Amount

Signed this the ______day of ______, 20______.

Signature of Affiant Printed Name of Affiant

THE STATE OF TEXAS § COUNTY OF DALLAS §

BEFORE ME, the undersigned authority, on this day personally appeared the above named affiant who upon oath, stated that he/she is the Tenant making this Pauper’s Affidavit and that the information provided is true and correct.

Subscribed and sworn to before me on this the ______day of ______, 20______

______Notary Public or Clerk of Court

CERTIFICATE OF DELIVERY: I the Defendant in the above and entitled forcible detainer / forcible entry and detainer certify that I have sent the forgoing document to the opposing party on this the ______day of ______, 20______.

Signature of Defendant Printed Name of Affiant

Judge Katy Hubener Justice of the Peace 4-2 Dallas County, Texas 841 West Irving Boulevard Irving, TX 75060 P. (214) 589-7000 F. (214) 589-7048 Form 6a Affidavit of Indigency (Financial Inability to Post Bond or Pay Fine) – Class C. Misdemeanor Case Page 1 of 3 No. THE STATE OF § IN THE JUSTICE TEXAS COURT VS. § PCT. ____ PLACE ______(DEFENDANT § ______COUNTY, TEXAS ) I, ______, am the Defendant in the above–styled cause. I am not represented by counsel in this proceeding. I have no assets except the following. Employed By:______Address of Employer: ______My Earnings Are: $ ______Per Week $ ______Per Month I have other income as follows: (State Source and Amount): I am ______Married ______Single ______Divorced Number of Children: ______and other dependents: ______Amount of monthly Court Ordered support Paid/Received: $______I own the following property: Home (Address): ______Other: ______Monthly Payments: $ ______Balance Owed: $ ______I do not own real estate, but am renting premises located at: ______Monthly Rental: $ ______List Car/Truck Owned: ______Monthly Payment: $______Balance $ ______Notes, Mortgages, Trust Deeds Owned:______

Judge Katy Hubener Justice of the Peace 4-2 Dallas County, Texas 841 West Irving Boulevard Irving, TX 75060 P. (214) 589-7000 F. (214) 589-7048