Financial Affidavit and Affidavit of Indigency

City of Austin Municipal Court Financial Disclosure and Affidavit of Indigency

Please select the option that best describes your financial situation:*

I am able to pay in full and/or meet the standard monthly payment requirement but need an extension to pay. The standard monthly payment is $75 or the total due to the court divided by 12 - whichever is greater. I would like a payment plan but cannot meet the standard monthly payment requirement. I would like to do community service and have already been declared indigent. I need to discuss my ability to pay or perform community service with a judge. I am receiving aid from a federal assistance program for myself or a dependant (i.e. food stamps; Temporary Assistance for Needy Families (TANF); Women, Infants and Children (WIC); Children's Health Insurance Program (CHIP); Medicaid, Section 8; disability). I am required by law to attend school and am under the age of 19. I am indigent and have a physical or mental health disability that prevents me from performing community service. I seek to be exempted from work in the spirit of the "reasonable accommodation" clause of the Americans with Disabilities Act. I am under the conservatorship of the Department of Family and Protective Services or in extended foster care.

I am able to pay this amount monthly:* $

I can start making monthly payments on*

I can perform this number of hours of community service per month:*

I can start performing community service on*

Personal Information

Name*

First Name

Last Name

Other Names Used (Alias, Maiden Name, etc.)

Date of Birth*

Case Number(s)

Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Residence Address (if different from mailing address)

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Do you have a drivers license?*

Yes No

Driver's License Number*

State of Driver's License*

State/Province

Country of Driver's License*

Country

Do you have a State-issued ID card?*

Yes No

ID Number*

State of ID*

State/Province

Country of ID *

Country

Are you currently employed?*

Yes No

Employer's (Business) Name*

Employer's Phone Number*

Employer's Address*

Address Line 1

Address Line 2

City

State

ZIP Code

1st Reference Name*

First Name

Last Name

1st Reference Phone Number*

1st Reference's Relationship to You*

2nd Reference Name*

First Name

Last Name

2nd Reference Phone Number *

2nd Reference's Relationship to You*

Defendant will sign by using*

Mouse or finger pad Text fields (compatible with screen readers)

Date Defendant Signed*

I am requesting the standard payment plan and affirm I understand the terms, have the ability to successfully make the payments, and decline the opportunity for courtstaff to consider lower monthly payments or longer payment terms.*

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Use your mouse or finger to draw your signature above

First Name

Initial (optional)

Last Name

Additional Information Required

Income from Worker's Comp* $

Income from Pension(s)* $

Income from Social Security* $

Income from Child or Spousal Support (Received)* $

Income from Federal Assistance* $

Income from Disability* $

Other Income* $

Total Income $

Are you married?*

Yes No

Spouse's Monthly Income

Gross Income from Employment* $

Income from Unemployment* $

Income from Worker's Comp* $

Income from Pension(s)* $

Income from Social Security* $

Income from Child or Spousal Support (Received)* $

Income from Federal Assistance* $

Income from Disability* $

Other Income* $

Spouse's Place of Employment*

Address of Spouse's Place of Employment*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone Number of Spouse's Place Of Employment*

Spouse's Total Income $

Monthly Expenses

Child or Spousal Support (paid out)* $

Child care (if working)* $

Transportation for Work (car payment, bus pass, etc.)* $

Insurance* $

Medical/Dental* $

Medical and Associated Costs of Caring for Sick Family Members* $

Rent/Mortgage* $

Food* $

Electric* $

Gas* $

Fuel* $

Phone* $

Cable/Internet* $

Water/Sewer/Trash* $

Credit Cards* $

Loans* $

Taxes Owed* $

Other* $

Total Expenses $

Assets

Checking Account Balance* $

Name of Bank*

Savings Account Balance* $

Name of Bank*

Cash on Hand* $

Value of Vehicles* $

Length of Ownership and Make/Model/Year*

Value of Real Estate* $

Length of Ownership*

Stock/Bonds/CDs* $

Other Valuable Property (input value)* $

Total Value of Assets $

Defendant's Signature

Defendant will sign using*

Mouse or finger pad Text field (compatible with screen readers)

Date Defendant Signed*

I swear or affirm that the statements made here are within my personal knowledge and are true and correct.*

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Use your mouse or finger to draw your signature above

I swear or affirm that the statements made here are within my personal knowledge and are true and correct.*

First Name

Initial (optional)

Last Name