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
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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
Are you currently receiving (check all that apply)
___ Food Stamps
___ Medicaid
___ Public housing
___ Temporary Assistance to Needy Families (TANF)
___ Supplemental Security Income (SSI)
Expenses (Monthly) Monthly Model version 3, p. 2 of 4
Payment Adopted 11/15/06 – Task Force on Indigent Defense
Rent or Mortgage Payment
Car Payment
Insurance (Life, Health, Car,
Homeowners, etc.)
Child Care
Child Support
Water
Gas
Telephone
Electricity
Food
Clothes
Medical
Cable TV or Satellite TV
Pager
Cell Phone
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 (name of the court) 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
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 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

Model version 3, p. 4 of 4
Adopted 11/15/06 – Task Force on Indigent Defense