I cannot afford my court fees.

The caption information will be on the first page of the Statement. The caption information includes:

• the cause number,
• the party’s names,
• the court, and
• the county.

If the cause number is not already entered, the clerk will enter it for you when you turn in the document.

Write the Plaintiff’s and Defendant’s names as they appear on your court document.

Next, fill in the court number and the county. Then, check the box next to the type of court you are in.

□ District Court
□ County Court
□ County Court at law
□ Justice Court
□ Probate Court

Section 1, page 2 is where you can fill in your contact information.

This form asks for your address. The other side may get a copy of this form. If you are worried about the other side knowing your address, you can submit a sworn document that does not list your address instead of this form. Call the Family Violence Legal Line at 800-374-4673 for free advice.

On Section 2, page 3, you will enter your dependents.

There is a space in this section to list any of your dependents. A dependent is anyone who relies on you for financial support. Typical examples are your children, your parents, or your spouse if they don’t work and pay for their living expenses.

Use initials only for children under age 18.

If you do not have any dependents, simply write “N/A” on the first line of this space.

Section 3, page 4 is where you will check the box telling the court whether you are represented by legal aid.

If you applied for legal aid representation and qualified for their services, this is a sign that you are unable to afford court costs. Learn more at Qualifying for Legal Aid. Eligibility for various legal aid programs is often based on the federal poverty guidelines.

You must attach a letter from the legal aid showing that you qualified for their services.

If you meet the financial eligibility criteria for legal aid, it does not necessarily mean that they can handle your case due to limited resources. If you find yourself in this situation, make sure to include a letter from the legal aid organization as an attachment.

Section 4, page 5, is where you will check the box telling the court whether you receive public benefits.

Select each box that describes a public benefit you receive.” If you select “other,” you must describe the benefit you receive in the space next to that choice. You must also attach some proof of the benefit, such as an award letter.

If you get government benefits because you are poor, attach proof (such as a copy of an eligibility form or check) to your Statement.

Section 5, on pages 6 and 7, is where you will list all the ways you receive an income. Do not leave any spaces blank in this section. If you do not receive any income from a listed source, write “$0” in the amount space and “N/A” in the description space.

If you need more space to describe “other sources of income,” attach another page to the form with the description, and write “See attached Exhibit” in the space provided.

Section 6, page 8, is where you will list all your investments and property. Do not list the value of your household furnishings, clothing, tools of a trade, or personal effects.

The “value” of property means the amount it would sell for after subtracting the amount you still owe for it. The value is not the amount you paid for the property unless it would still sell for the same amount, and you don’t owe any money on it.

Sometimes it is hard to decide how much property would sell for. This is usually not a set amount, so you must estimate the amount based on how much a similar piece of property in your area would sell for. Here are some online resources you can use to decide the sale value of a piece of property:

• For an automobile, you can enter your car’s information on KelleyBlueBook.com.
• For real estate, you can look at the market value listed on your county’s appraisal district website.
• For other properties, you can look at how much similar items are selling for on an auction site like ebay.com.

Section 7, page 9, is where you will list all your expenses. The court wants to know if you have any leftover income you can use to pay court fees after your other expenses are met. It is important not to leave spaces blank on this section. If you do not have an expense for a listed category, write “$0” in the amount space.

It is unlikely that you will have zero dollars for monthly expenses for many of these. Don’t leave an expense out just because you are having a tough time estimating the monthly amount.

Here are some tips if you are stuck:

• If it is a yearly expense, instead of a monthly expense, divide the yearly amount by 12 to find the monthly amount.
• If it is a one-time expense that you are still making credit payments on it, you can put your monthly payment as the monthly amount.
• If it is an irregular expense, you can also add up the approximate yearly amount and divide by 12. For instance, let’s say you spend money on clothes, but you don’t buy clothes every month. Just add up the total amount you spent on clothes for the year, and divide by 12.

Section 8, page 10, is where you tell the court about other debts or financial difficulties that you were unable to explain in any of the sections above. You do not have to write anything in this section.

• Sections 9, on page 10, is where you will tell the court that you are not able to pay court costs or the appeal bond. Put an “X” in the box that applies. Only select the second box if you are filing an appeal of a justice court decision.
  Declaration & Signature Options
• Section 10, on Pages 11 through 13, is your declaration to the court. It also shows the two ways you can sign this document. You can sign this document by self-certifying that everything you put on this document is correct, or you can sign this document in front of a notary public.
• Remember, you are swearing an oath that everything you say in this form is true.

If you want the judge to consider other facts, such as unusual medical expenses or family emergencies, attach a separate page with that information. Write “Exhibit: Additional Supporting Facts” at the top of the page. 

See section 8 of the statement on page 10.

Turn in your completed Statement or sworn document at the clerk’s office when you file your other court forms.