(a) Required information. An affidavit under Texas Finance Code, §348.013(m) filed with the hearings officer must contain the following information:
  (1) the name of the prospective retail buyer;
  (2) a statement by a notary public identifying the prospective retail buyer, and stating that the prospective retail buyer personally appeared before the notary and made the statements under oath;
  (3) the following statement: "I am over 18 years of age and am capable of making this affidavit. The facts stated in this affidavit are within my personal knowledge and are true and correct. Due to my financial situation, I cannot afford to pay the deposit required under Texas Finance Code, §348.013(m). I wish to appeal the Consumer Credit Commissioner's determination under §348.013(g) regarding my conditional delivery agreement with (Insert Name and Address of Retail Seller and OCCC license number). The following information accurately states my income, assets, expenses, and liabilities.";
  (4) nature and amount of monthly income from the following sources:
    (A) employment;
    (B) government entitlement;
    (C) spouse, if spouse's income is available to the prospective retail buyer; and
    (D) any other income;
  (5) type and approximate value of property owned (other than homestead), including make, model, and year of any motor vehicles owned;
  (6) checking or savings account information, including:
    (A) name and location of financial entity;
    (B) approximate amount of money held in account;
  (7) approximate amount of any cash on hand;
  (8) monthly expenses, including expenses from the following example sources:
    (A) rent/mortgage;
    (B) utilities;
    (C) food;
    (D) child care;
    (E) child support;
    (F) health care;
    (G) car payment;
    (H) transportation;
    (I) insurance;
    (J) clothes/laundry;
    (K) finance charges; and
    (L) any other monthly expenses;
  (9) information regarding debts and other liabilities, including:
    (A) name of creditor;
    (B) total debt amount; and
    (C) monthly payment;
  (10) number of dependents;
  (11) the following statement: "As the prospective retail buyer, I am unable to pay the deposit required by Texas Finance Code, §348.013(m) for the appeal of the Consumer Credit Commissioner's conditional delivery determination. I verify that the statements made in this affidavit are true and correct.";
  (12) the date the affidavit was signed;
  (13) the prospective retail buyer's signature and printed name;
  (14) the prospective retail buyer's address; and
  (15) the notary public's seal and signature.
(b) Filing. The affiant should file the affidavit with the hearings officer through the commissioner.
(c) Commissioner's evaluation. The commissioner will use the poverty guidelines updated periodically in the Federal Register by the U.S. Department of Health and Human Services under the authority of 42 U.S.C. §9902(2) when evaluating an individual's affidavit for waiver of the deposit required by Texas Finance Code, §348.013(m). The commissioner will consider the particular financial situation of the affiant in the process of determining whether the affiant's request for wavier of the deposit should be granted.
(d) Sample affidavit. A sample affidavit under Texas Finance Code, §348.013(m) is presented in the following example.
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Source Note: The provisions of this §84.105 adopted to be effective September 10, 2009, 34 TexReg 6104; amended to be effective November 8, 2012, 37 TexReg 8780