In the Matter of # In the District Court
The Marriage of #
#
# of Dallas County, Texas
#
And In the Interest of #
# 330th Judicial District Court

Affidavit of Indigency and Request
For Appointment of Attorney

STATE OF TEXAS #
#
COUNTY OF DALLAS #

BEFORE ME, the undersigned authority, on this day personally appeared
________________________________, who being by me duly sworn, on oath stated:

I am the Respondent in this cause. I cannot afford representation. I am requesting that the Court conduct an Indigency Hearing and appoint an attorney to represent me. In support of this request, I offer the following evidence:

MONTHLY INCOME Amount Source
a) Public Benefits ___________ __________
b) Net Employment ___________ __________
c) Other Income ____________ ___________
Number of Dependents ___________
Property:
a) Cars, trucks, vehicles _____________________________
b) Checking account ____________ ___________
c) Savings account ____________ ___________
d) Retirement account ____________ ___________
e) Cash on hand ____________ ___________
f) Other property of value _____________________________
_____________________________

AFFIDAVIT OF INDIGENCY
Page Two

Monthly Expenses:

a) Rent/mortgage ______________
b) Car payment ______________
c) Insurance ______________
d) Child care ______________
e) Food ______________
f) Medical/dental ______________
g) Utilities ______________
h) Transportation ______________
i) Clothing/laundry ______________
j) Other ______________
Total ______________

Creditors:

a) _____________________ _______________
b) _____________________ _______________
c) _____________________ _______________
d) _____________________ ________________

I, _____________________, state on oath, that this Affidavit is true and correct, and is within my personal knowledge.

SIGNED this _____________ day of ___________________, 2004.

_____________________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, on this ______ day of ___________,
2006.

_____________________________
Notary Public In and For
The State of Texas