Texas Driver Responsibility Program Financial Affidavit
Information reflected in this affidavit is the basis for assessing the affiant’s ability to pay surcharges. To qualify for a reduction in surcharges, affiant must be living at or below 125% of the federal poverty line.Download
Extracted Text for Proper Search
TEXAS DRIVER RESPONSIBILITY PROGRAM Financial Affidavit (In support of request for reduction of surcharge payment) IND‐1 (Rev. 04/11) Page 1 Print Full Name: _______________________________________ DL/ID/DPS Assigned Number: ____________________________ MSB Account Number(s):________________________________ All questions must be answered in full and the form notarized for the application to be reviewed. The following information will be used to determine your ability to pay your surcharge(s). You must be living at or below 125% of the federal poverty level to qualify for a reduction. NOTE: You may be randomly selected to submit supporting document(s) based on your answers to the following questions. Employment: (Provide gross income, before taxes) Are you now employed? Yes No Self Employed If yes, what is the Name and Address of employer: _____________ _______________________________________________________ If yes, how much do you earn per month?_____________________ If no, give date of last employment and how much you earned per month? ________________________________________________ If no, how much do you earn per month in unemployment?_______ If you are married, what is your spouse’s monthly income?________ If you are a dependent, what is your parent/guardian’s monthly income? ______________________________________________________ Other income: Have you received within the past 12 months any income from a business, profession or other form of self‐employment, or in the form of rent payments, interest, dividends, retirement or annuity payments, or other sources? Yes No If yes, give the amount received and identify the sources. Received Sources Cash: Do you have any cash on hand or money in a savings and/or checking account? Yes No If yes, state the total amount._______________________________ Dependents: Marital Status Single Married Widowed Separated/Divorced Total Number of Dependents you support: ____________________ List any persons you actually support and your relationship to them. _________________________________________________ ___ _________________________________________________ ___ _________________________________________________ ___ COMPLETE NOTARIZATION ON THE BACK SIDE BEFORE SUBMITTING TEXAS DRIVER RESPONSIBILITY PROGRAM Financial Affidavit (In support of request for reduction of surcharge payment) IND‐1 (Rev. 04/11) Page 2 OATH BEFORE NOTARY PUBLIC STATE OF ___________, COUNTY OF________________, BEING FIRST DULY SWORN, UNDER OATH, SAYS: THAT HE/SHE IS THE APPLICANT IN THIS ACTION AND KNOWS THE CONTENT OF THE ABOVE APPLICATION AND CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. Signature of Applicant SUBSCRIBED AND SWORN TO BEFORE ME THIS ____ ____ DAY OF ____________________, 20_________ ___________________________________ ____ Signature of Notary Public Please mail the original notarized form to: PLEASE ENTER ADDITIONAL INFORMATION IN THIS SPACE _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ ____________________________________________________ PO BOX 16733 – AUSTIN, TX 78761‐6733 TOLL FREE (866) 223‐3583 Mon – Thur 8AM– 9PM, Fri 8AM – 6PM Saturday 8AM – 12PM
If you want to remove Texas Driver Responsibility Program Financial Affidavit from this website please contact us providing the reasons together with this url: https://formsarchive.com/texas-driver-responsibility-program-financial-affidavit/