On the ______ day of ________________, 20___, Defendant was convicted by this Court of an offense for which surcharges are assessed under Texas Transportation Code, Chapter 708, to wit: Driving While Intoxicated, which offense occurred on _______________________.
The Court, having heard the evidence presented by the Defendant, and having reviewed all documentation provided, makes the following findings:
. The Defendant’s income or the Defendant’s household income does not exceed 125% of the applicable income level established by the federal poverty guidelines; or
2. The Defendant, or the taxpayer claiming the Defendant as a dependent, receives assistance from one of the programs outlined in Section 708.158(b)(3) of the Transportation Code.
The Court finds the Defendant is indigent.
This is the Court in which the Defendant was convicted of the offense that is the basis for the surcharge.
It is therefore ORDERED that the Texas Department of Public Safety shall WAIVE all surcharges assessed under Texas Transportation Code, Chapter 708, for the Defendant as a result of the conviction in the above entitled and numbered cause.
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Presiding Judge