Form Center

2. 
4. Indigency Questionnaire
6. First Name*
7. Last Name*
9. Cause Number (s)
11. Please check the appropriate box

    1. I assert that I am unable to pay the fine and costs immediately and that the following information is documentation that I have insufficient resources or income to pay today.
    2. I request that I be able to discharge the fine and costs by performing community service, because I have no resources to pay and I am unable to pay the fine and costs.
    3. I have been determined to be indigent by the federal government and I am receiving or I am eligible to receive assistance under a federal program.
13. Name Federal Program
17. Address *
19. City*
20. State*
21. Zip*
23. Phone Number*
24. Email Address*
26. Date of Birth*
27. Driver's License Number*
31. Your Employer
32. Position/Title
34. Address
35. How long have you work at your current position
37. City
38. State
39. Zip Code
41. Salary
42. Per

    1. Hour
    2. Weekly
    3. Monthly
    4. Annually
43. Marital Status

    1. Married
    2. Single
    3. Divorced
    4. Widowed
45. Spouse's First Name
46. Spouse's Last Name
48. Employer
49. Position/Title
50. Salary - Annually
54. List all of your dependents, ages and relationship to you.
55. List other sources of income, including any financial aid
57. Your Residence is

    1. Owned
    2. Rented
    3. Rent-Free
58. Banking (Check all that apply)

    1. Checking
    2. Savings
    3. Other
59. List total available balance in all accounts
61. List all real estate owned by you and your spouse
63. Total Income
67. List all of your Monthly Expenses in dollars
69. Home Mortgage payment, rent or lot rental
70. Utilities, Electric, Water, Gas, Telephone, Garbage
71. Food, Clothing, Laundry, & Cleaning
72. Medical, Dental & Prescription Drugs
74. Insurance, Auto, Life, Medical, Homeowners & Renters
75. Transportation, including auto payments
76. Taxes not deducted from wages or included in mortgage
77. Alimony, support payments, religious/charitable
79. List all your creditors including credit cards and the amount you owe on each.
80. Creditors
82. Other expenses not listed
84. Total Expenses
88. Provide a value for all personal property owned by you and your spouse
90. Cash on hand
91. Household goods, furniture, appliances
92. Jewelry, sports equipment, musical instruments
93. Home theater, media, stereo and TV equipment
95. Autos, trucks, trailers, boats, ATV, tools, and lawn equipment
96. Farming equipment, supplies, livestock, horses, supplies
100. Upload supporting documents of financial status
104. 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.

106. Signature of Defendant*

     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.

     NOTE: Please make sure to check your spam folder for a reply from the Court Clerk. Some email communications may be directed to your spam folder by your current settings on your email account.

Leave This Blank:


108. 1. Receive an email copy of this form.
109. Email address

     This field is not part of the form submission.

110. Submit Submit and Print

* indicates a required field