Case No: Cause: _________________

State of Texas Vs. __________________

§ § § § § §

Court:_____________________ ______________ County, Texas

July 11, 2024

AFFIDAVIT OF INABILITY TO PAY (IN FORMA PAUPERIS)

BEFORE US, the undersigned authority, on this day personally appeared Richard Renfro, being of sound mind and body, who swore on oath, states:

My name is Name:________________________, I am the accused in the above referenced cause, defending the criminal charge of not wearing a seat belt.

I am currently without funds for an attorney, and cannot afford to hire one for this case. I know of no attorney that will pay or advance court costs or provide free legal services to me without a contingency fee.

I only receive $_______________ a month from ______________________________________.

I have not had to pay income taxes for the last few years, but because I have not had enough income to be required to do so.

I have no other income and do not qualify for any form of governmental income other than social security.

I have no cash on hand or available to withdraw, and I own no insurance policies with a cash value.

I have normal monthly expenses and debts, the amounts of which vary

Electric $________

Phone $________

Auto Insurance $________

Car Payment $________

Internet $________

Natural Gas $________

Sewer & Water $_________

Groceries $__________

$Mortgage $__________

☐ See Additional Items Attached

Respectfully Submitted

Sign: _________________________________

Namee:________________________________

Address:_______________________________

City: _______________ St: ____ Zip: _______

Jurat

I, Randall Kelton, do swear and affirm that all statements made herein are true and accurate, in all respects.

Sign: __________________________________

Namee:_________________________________

Address:________________________________

City: _______________ St: ____ Zip: _______

SWORN TO AND SUBSCRIBED BEFORE ME, __(notariy's name)___, by (your name), on the ______ day of ____________, 20__, which witnesses my hand and seal of office.

Stamp Here

_________________________________

NOTARY PUBLIC IN AND FOR

THE STATE OF TEXAS