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Indigency Questionnaire

  1. News Placeholder
  2. Indigency Questionnaire
  3. Please check the appropriate box
  4. Per
  5. Marital Status
  6. Your Residence is
  7. Banking (Check all that apply)
  8. List all of your Monthly Expenses in dollars
  9. List all your creditors including credit cards and the amount you owe on each.
  10. Provide a value for all personal property owned by you and your spouse
  11. Agreement

    PLEASE READ THE FOLLOWING STATEMENTS BY SIGNING THE FORM THIS INDICATES THAT YOU HAVE READ THE STATEMENTS, UNDERSTAND,  AND AGREE TO THEM.

    I promise that I will notify this Court in person or by first-class mail of any changes of my address or telephone number at the following address Wilmer Municipal Court 219 East Beltline Road Wilmer, TX 75172 within five (5) days of the change.

    I understand that submitting false financial information to the Court constitutes the crime of tampering with a governmental record, punishable by incarceration and/or the imposition of a fine (Section 37.10, Penal Code). I swear that all the information in this application is true, correct, and complete to the best of my knowledge belief.

  12. By signing this form you agree and acknowledge that 1) your application will not be "Signed" in the sense of a traditional paper document and 2) By signing in this alternate manner, you agree that your electronic signature is valid and binding upon you to the same force and effect as a handwritten signature.

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  14. This field is not part of the form submission.