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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

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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
 
 
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PO BOX 16733 – AUSTIN, TX 78761‐6733 
 
TOLL FREE (866) 223‐3583 
Mon – Thur 8AM– 9PM, Fri 8AM – 6PM 
Saturday 8AM 	
–12PM
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