What is your monthly income and income sources? get this monthly income: “I $ in monthly I work as a for . Your job title Your employer $ in monthly unemployment. I have been unemployed since . (date) $ in public benefits per month. $ from other people in my household each month: (List only if other members contribute to your household income.) $ from Retirement/Pension Tips, bonuses Disability Worker’s Comp Social Security Military Housing Dividends, interest, royalties Child/spousal support My spouse’s income or income from another member of my household (If available) $ from other jobs/sources of income. (Describe) $ is my total monthly income. What is the value of your property? 6. What are your monthly expenses? property includes: monthly expenses are: Amount “My “My Cash Rent/house payments/maintenance $ $ Bank accounts, other financial assets Food and household supplies $ Utilities and telephone $ $ Clothing and laundry $ $ Medical and dental expenses $ $ Vehicles (cars, boats) Insurance (life, health, auto, etc.) $ (make and year) School and child care $ $ Transportation, auto repair, gas $ $ Child / spousal support $ $ property (like jewelry, stocks, land, Wages withheld by court another house, etc.) order $ Debt payments paid to: $ $ (List) $ $ $ $ Total value of property Total Monthly Expenses $ $ *The value is the amount the item would sell for less the amount you still owe on it, if anything. 7. Are there debts or other facts explaining your financial situation? include: “My (List debt and amount owed) “ (If you want the to consider other facts, such as unusual medical expenses, family emergencies, etc., attach another page to Check here if you attach another page. this form labeled Additional Supporting Facts.”) “Exhibit: 8. Declaration I declare under penalty of perjury that the foregoing is true and correct. I further swear: I cannot afford to pay court costs. I cannot furnish an appeal bond or pay a cash deposit to appeal a justice court decision. My name is . My date of birth is : / / . My address is Street City State Zip Code Country signed on / / in County, Signature county name
What is your monthly income and income sources? “I get this monthly income: $ in monthly I work as a for . Your job title Your employer $ in monthly unemployment. I have been unemployed since (date) . $ in public benefits per month. $ from other people in my household each month: (List only if other members contribute to your household income.) $ from Retirement/Pension Tips, bonuses Disability Worker’s Comp Social Security Child/spousal support Military Housing Dividends, interest, royalties My spouse’s income or income from another member of my household (If available) $ from other jobs/sources of income. (Describe) $ is my total monthly income. What is the value of your property? 6. What are your monthly expenses? “My property includes: “My monthly expenses are: Amount Cash $ Rent/house payments/maintenance $ Bank accounts, other financial assets Food and household supplies $ $ Utilities and telephone $ $ Clothing and laundry $ $ Medical and dental expenses $ Vehicles (cars, boats) (make and year) Insurance (life, health, auto, etc.) $ $ School and child care $ $ Transportation, auto repair, gas $ $ Child / spousal support $ property (like jewelry, stocks, land, another house, etc.) Wages withheld by court order $ $ Debt payments paid to: (List) $ $ $ $ $ Total value of property $ Total Monthly Expenses $ *The value is the amount the item would sell for less the amount you still owe on it, if anything. 7. Are there debts or other facts explaining your financial situation? “My include: (List debt and amount owed) “ (If you want the to consider other facts, such as unusual medical expenses, family emergencies, etc., attach another page to this form labeled “Exhibit: Additional Supporting Facts.”) Check here if you attach another page. 8. Declaration I declare under penalty of perjury that the foregoing is true and correct. I further swear: I cannot afford to pay court costs. I cannot furnish an appeal bond or pay a cash deposit to appeal a justice court decision. My name is . My date of birth is : / / . My address is Street City State Zip Code Country signed on / / in County, Signature county name
Appeal-Eviction-with-Statement-of-Inability-to-Pay-Court-Cost-2017.docx