Unsworn Declaration Indigency Form PDF Details

If you’re looking for financial assistance with court costs, or help paying a filing fee in your civil case, you may be able to avoid having to pay out of pocket if you qualify as “indigent.” An "unsware declaration of indigency" form filed with the court is one way qualified individuals can assert their right not to have certain expenses waived. Knowing how and when to file an affidavit can make the process more straightforward and ensure that your rights are protected. In this blog post, we'll discuss what an unsworn declaration of indigency is and provide detailed instructions about filling out the form so that applicants can receive due diligence from courts without issue.

QuestionAnswer
Form NameUnsworn Declaration Indigency Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdeclaration of indigincy, umc indigent program, declaration of indigency, unsworn declaration indigency

Form Preview Example

NOTICE: THIS DOCUMENT CONTAINS SENSITIVE DATA.

Cause Number:

(The Clerk’s office will fill in the Cause Number when you file this form.)

Petitioner/

Plaintiff

In the:

Court Number

District Court

County Court at Law

Justice of the Peace

Respondent/ Defendant

County, Texas

Unsworn Declaration of Indigency

1.I am filing this Unsworn Declaration of Indigency in place of an Affidavit of Indigency as allowed by Section 132.001 of the Texas Civil Practices and Remedies Code.

2.I am unable to pay court costs. I declare under penalty of perjury that the statements made in this Unsworn Declaration of Indigency are true and correct.

3. My name is:

 

 

 

 

.

 

 

First

 

Middle

 

Last

 

 

My date of birth is: _______/_______/________.

 

 

 

 

 

 

Month

Day

Year

 

 

 

 

My address is:

 

 

 

 

 

 

.

 

 

Street Address

 

City

State

Zip

Country

My email address is:

 

 

 

 

 

 

.

4.Government Entitlements (Check one.)

I do not currently receive any government entitlements based on indigency (poverty). I currently receive the following government entitlements based on indigency (poverty):

Government entitlements based on indigency include but are not limited to: Food Stamps/SNAP, TANF, SSI, Medicaid, WIC Chip, AABD, Needs-based VA Pension, Public Housing, County Assistance, County Health Care, General Assistance, LIS in Medicare (“Extra Help”), Community Care via DADS, Low-Income Energy Assistance, Emergency Assistance, Child Care Assistance under Child Care and Development Block Grant.

List all government entitlements based on indigency received by you or your dependents and the dollar amount of the benefit if applicable. Attach proof of the government entitlements received to this form.

Name of Public Benefit

 

Person Getting the Benefit

 

Dollar Amount

 

 

 

 

$

 

 

 

 

$

 

 

 

 

$

5.Income

a.

My net monthly income from employment (after taxes) is:

$____________

 

 

or

I am not currently employed or self-employed.

 

 

b.

My spouse’s net monthly income (after taxes) is:

$____________

 

or

I am not married. or

My spouse’s income is not available to me.

 

 

c.All other income I receive is listed below: List the source of income (i.e. unemployment, retirement, social security, interest, dividends, child support, spousal support) and the monthly amount you receive.

$

$

$

© TexasLawHelp.org, Declaration of Indigency, December 2014

Page 1 of 2

Texas Rules of Civil Procedure, Rule 145 and Texas Civil Practice & Remedies Code, Rule 132.001

 

6. Dependents – The people who depend on me financially are listed below:

Name

 

Age

 

Relationship to Me

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. Property – I own the following property:

List the property and its value - the amount the property would sell for less the amount you still owe on it. If there is no property in a particular category, write “none.”

Bank Accounts (list bank, type of account and amount of $ in account)

$

$

Vehicles (list make and year)

$

$

Real Estate – House or Land (do not list the house you live in)

$

$

Other Property of Value (like boats, jewelry, stocks, etc.)

$

$

$

8. Monthly Expenses – I have the following monthly expenses:

Rent / Mortgage

$

 

Insurance (auto, life, health, etc.)

$

Food

$

 

Vehicle payments

$

Utilities (electric/gas)

$

 

Gas, bus fare, auto repair

$

Telephone

$

 

Child support / spousal support

$

Clothing and laundry

$

 

Other expenses/debts: (describe)

$

Medical, dental expenses

$

 

 

 

$

Child care, school tuition

$

 

 

 

$

Household supplies

$

 

 

 

$

 

 

 

Total monthly expenses:

$

9.Additional Information

List any other facts you want the court to know, such as unusual medical expenses, family emergencies, etc.

10. Formally signed under penalty of perjury in

 

County, Texas on this

date: ______/_______/_______.

 

 

 

 

 

 

Your Signature

 

 

© TexasLawHelp.org – Declaration of Indigency, December 2014

Page 2 of 2

Texas Rules of Civil Procedure, Rule 145 and Texas Civil Practice & Remedies Code, Rule 132.001

 

How to Edit Unsworn Declaration Indigency Form Online for Free

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When it comes to blank fields of this precise form, here is what you should do:

1. The wilco indigent program needs certain details to be typed in. Make sure the subsequent blank fields are completed:

Filling out part 1 of declaration of indigincy

2. The next part would be to complete all of the following fields: Government Entitlements Check one, I do not currently receive any, List all government entitlements, Name of Public Benefit, Person Getting the Benefit, Income, Dollar Amount, I am not currently employed or, a My net monthly income from, My spouses income is not available, and I am not married or.

Completing part 2 of declaration of indigincy

3. Completing a My net monthly income from, social security interest dividends, TexasLawHelporg Declaration of, and Page of is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

declaration of indigincy conclusion process described (part 3)

4. The subsequent subsection will require your information in the subsequent areas: Name, Age, Relationship to Me, Property I own the following, List the property and its value, Bank Accounts list bank type of, Vehicles list make and year, Real Estate House or Land do not, and Other Property of Value like boats. Make certain to give all of the required information to go forward.

Filling in part 4 of declaration of indigincy

Always be really careful when filling out Relationship to Me and Real Estate House or Land do not, as this is the part in which most users make some mistakes.

5. This pdf has to be concluded within this segment. Here you will notice an extensive list of blank fields that need accurate information to allow your document submission to be faultless: Monthly Expenses I have the, Rent Mortgage Food Utilities, Child care school tuition, Household supplies, Additional Information, Insurance auto life health etc, Vehicle payments Gas bus fare auto, Total monthly expenses, List any other facts you want the, Formally signed under penalty of, County Texas on this, date, Your Signature, TexasLawHelporg Declaration of, and Page of.

declaration of indigincy writing process shown (part 5)

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