DECLARATION IN SUPPORT OF PROXY

 

I, ________________________________, TDCJ No.or TX Inmate No.___________________of

_______________________Unit/Jail name in ____________________________County, Texas, on my oath say and declare that I am eighteen (18) years of age or older and not incapacitated in any way and that the statements herein set forth including answers to questions propounded constitute a true, correct, and complete statement and declaration.

1.                  FULL NAME (including maiden name):_______________________________________

2.                  ADDRESS:______________________________________________________________

            UNIT OR COUNTY______________________City_______________________, Texas   

3.                  DATE OF BIRTH:________________________________________________________

Month/Day/Year

4.                  PLACE OF BIRTH:_______________________________________________________

City/County/State

5.                  CITIZENSHIP:___________________________________________________________

6.                  SOCIAL SECURITY NO: _________________-___________-____________________

7.                  Have you been divorced within the last 30 days? _____________Yes  ____________No

a.       Date of divorce or annulment:____________________________________________

Month/Day/Year

8.                  Are you presently married? ______________Yes _______________No

9.                  Are you related to the other applicant as:

a.                   an ancestor, or descendant, by blood or adoption;

b.                  a brother or sister, of the whole or half blood, or by adoption;

c.                   a parent’s brother or sister of the whole or half blood;

d.                  a son or daughter of a brother of sister of the whole or half blood or adoption.

________________Yes          ________________No

10.              Are you presently delinquent in any court ordered child support payments?

________________Yes          ________________No

11.              I hereby declare that I desire to marry ________________________________________.

Whose age is __________and whose address is _________________________________

________________________________________________________________________

12.              The approximate date this marriage will occur is ________________________________.

13.              I am unable to appear in person before the County Clerk for the issuance of the license because I am incarcerated at the _____________________________________________.

TDCJ and Unit or Name and County of jail

14.              I will not be able to attend the ceremony and for that reason, I hereby appoint to act as proxy __________________________ for the purpose of participating in the ceremony.

 

I, ________________________________, TDCJ or Inmate No. _____________, being presently

                        Full Name

incarcerated in ___________________________ in _______________________County, Texas,

                          TDCJ unit name or County jail name                                               

declare under penalty of perjury that the foregoing is true and correct.  Executed on the ________day of ___________________, 20____.

_____________________________________

                                                                                                DECLARANT

 

PURSUANT TO TITLE 6, TEXAS CIVIL PRACTICE AND REMEDIES CODE, CHAPTER 132, SECTION 132.001 et seg.