Affidavit of Indigence: This Section To Be Filled Out by Court Personnel

AFFIDAVIT OF INDIGENCE
This section to be filled out by Court Personnel
No. ______________________
The State of Texas In the ___________________ Court
vs.
______________________________ ________________________County
Offense ______________________ Level of Offense _______________
All information must be completed by the defendant and must be current, accurate, and true.
Intentionally or knowingly giving false information may result in your prosecution for the offense
of aggravated perjury, a felony. The punishment for aggravated perjury includes imprisonment
not to exceed ten (10) years and a fine not to exceed ten thousand dollars ($10,000). Please fill in all
blanks. If you do not know the information being asked, enter DO NOT KNOW in the blank. If
the information being asked does not apply to you, enter N/A in the blank.
Defendant’s Personal Information

Name
Phone Number
Street Address
City, State, Zip
Social Security #
Driver’s License #
Date of Birth
Name of Spouse
Dependents:
Name(s) (list below): Age Relation Income
Are you currently in jail or in a correctional institution?

___ No
___ Yes If yes, provide name of institution:
Are you currently residing in a mental health facility?

___ No
___ Yes If yes, provide name of facility:
Do you have an application pending at a mental health facility?

___ No
___ Yes If yes, provide name of facility
Model version 3, p. 1 of 4
Adopted 11/15/06 – Task Force on Indigent Defense
Employer Information
Employer
Phone Number
Supervisor’s Name
Street Address:
City, State, Zip
Hours worked ___ per week or ___ per month
Pay rate
Spouse’s Employer
Street Address:
City, State Zip
Hours worked ___ per week or ___ per month
Pay rate
If unemployed, list:
Length of time unemployed
Name of previous employer
Street Address of previous employer:
City, State, Zip
Defendant’s Financial Information
Public Assistance Income (Monthly) Monthly

Are you currently receiving (check all that apply) Amount
___ Food Stamps Take Home Pay
___ Medicaid Spouse’s Take Home Pay
___ Public housing Investment Income
___ Temporary Assistance to Needy Families (TANF) Stock Dividend
___ Supplemental Security Income (SSI) Bond Dividend
Expenses (Monthly) Monthly Rental Income
Payment Pension Payments
Rent or Mortgage Payment Unemployment
Car Payment Social Security Benefits
Insurance (Life, Health, Car, Child Support
Homeowners, etc.) Public Assistance
Child Care
TANF
Child Support
SSI
Water
Gas Medicaid
Telephone Other
Electricity Cash Gifts
Food Other (Describe)
Clothes
Medical TOTAL GROSS
Cable TV or Satellite TV MONTHLY INCOME
Pager
Cell Phone Model version 3, p. 2 of 4
Loan and Debt Payments
Outstanding Loans (list type of Loans)
Credit Card Debt (list name of cards)
Balance: $__________
Balance: $__________
Other Monthly Expenditures (Describe)
TOTAL MONTHLY EXPENSES

Assets
Asset Value
A. Place of Residence ___ Rent ___ Own $
Describe if house, condominium, apartment, other:
B. Real Property Owned; Description/Location: $
C. Automobile(s)
Make Model Year $
Make Model Year
$
Make Model Year
$
D. Stock and Bonds (provide description)
$
$
E. Other Property (list all jewelry, equipment, watercrafts, etc.)
$
$
$
F. Bank Accounts
Bank Name Type of Account Balance
$
$
$
$
G. Other Assets (Identify) VALUE
$
ASSETS TOTAL VALUE $
I have / have not (circle one) attempted to hire an attorney. The names of the attorneys I have contacted are as
follows:
______________________________ _______________________________
______________________________ _______________________________
______________________________ _______________________________
On this ________ day of ____________, 20 ___, I have been advised by the _____________ Court of my right to
representation by counsel in the trial of the charge pending against me. I am without means to employ counsel of
my own choosing and I hereby request the court to appoint counsel for me. By signing my name below, I swear, that
all of the above information about my financial condition is current, accurate, and true.
_____________________________________________
Defendant’s Signature
SUBSCRIBED and SWORN to before me, the undersigned authority, this ___ day of ________________, 20___
_________________________________________
Clerk’s Signature
This court finds the defendant is / is not indigent.
_________________________________________
Signature of Judge
VERIFICATION AGREEMENT
I do / do not (circle one) authorize the court to verify the financial information given to
determine my eligibility by contacting my employer and/or other third parties who can confirm
the information provided. I understand that if I do not authorize the court to contact the
necessary parties, then I must provide verification of the information in a manner that is
acceptable to the court or I will not have an attorney appointed.
_______________________________
Applicant’s Signature
SUBSCRIBED and SWORN to before me, the undersigned authority, this ___ day of
________________, 20___
_____________________________
Clerk’s Signature
MY EMPLOYMENT INFORMATION:
JOB TITLE: ___________________________________________________

EMPLOYER'S NAME: ___________________________________________
EMPLOYER'S ADDRESS: ________________________________________
SUPERVISOR'S NAME: __________________________________________
WORK PHONE: _______________________________________________
HOURS OF WORK: _____________________________________________
PAY RATE: ___________________________________________________
MY FINANCIAL INFORMATION:
NAME OF FINANCIAL INSTITUTION: ________________________________

ACCOUNT NUMBER: ____________________________________________
BALANCE: ____________________________________________________
______________________________________________
SIGNATURE OF EMPLOYEE/PERSON SUBJECT TO FINANCIAL INFORMATION

Affidavit of Indigence: This Section To Be Filled Out by Court Personnel

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AFFIDAVIT OF INDIGENCE

This section to be filled out by Court Personnel

The State of Texas In the ___________________ Court

Offense ________ Level of Offense _

Defendant’s Personal Information

Are you currently in jail or in a correctional institution?

Are you currently residing in a mental health facility?

Do you have an application pending at a mental health facility?

Defendant’s Financial Information

Public Assistance Income (Monthly) Monthly

Credit Card Debt (list name of cards)

TOTAL MONTHLY EXPENSES

B. Real Property Owned; Description/Location: $

ASSETS TOTAL VALUE $

This court finds the defendant is / is not indigent.

JOB TITLE: ___________________________________________________

NAME OF FINANCIAL INSTITUTION: ________________________________

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