NO. [Cause Number] THE STATE OF TEXAS VS. [DEFENDANT NAME] DEFENDANT ) ) ) ) ) ) ) IN THE DISTRICT COURT [ TH] JUDICIAL DISTRICT [SUIT COUNTY] COUNTY, TEXAS
STATEMENT OF INABILITY TO AFFORD COUNSEL State of Texas County of _____________ ) )
On _________________, [Defendant Name] appeared BEFORE ME, and after being placed under oath made the following statements and affirmed their truth: "My name is [Defendant Name] and I am the Defendant in this cause. "I am not able to afford counsel in this cause because of my financial circumstances. "I receive income or financial payments by reason of government entitlement in the amount of $[Amount] from [Agency Disbursing Funds]. "The amount of income that I receive from all other sources is as shown on Exhibit A. "My property and my assets include the following: [Property Assets] Value [Amount]
The value of my property and assets is $[Total]. "My monthly expenses are as shown on the attached exhibit A, as well as calculations showing the deficiency between my monthly income and my expenses. "I do not have knowledge of any other source from which I can obtain funds to obtain the services of counsel. "I reaffirm that I am unable to afford counsel and I verify that the statements are true and correct."
"On _________________, I have been advised by the Court of my right to representation by counsel in the trial of the charges pending against me. I certify that I am without means to employ counsel of my own choosing and I hereby request the court to appoint counsel for me." _____________________ [Defendant Name]
State of Texas County of ____________
Subscribed and sworn to before me by _________________________ on _______________. ________________________________ Notary Public, State of Texas ________________________________ Notary's typed or printed name My commission expires: ____________ [or Notary's Stamp]