This government document is issued by Justice of the Peace Courts for use in Harris County, TX
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http://www.jp.hctx.net/forms/2013%20APPROVED%20FINAL%20RULES%20-%20WEBSITE%20DOWNLOADABLE%20FORMS/Affidavit-Medical%20Expenses%20(Custodian)%20CV%2018.001%20Rule%20902.pdf