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Affidavit Of Indigency - Tennessee

Affidavit Of Indigency Form. This is a Tennessee form and can be used in Circuit Court Knox Local County .
 Fillable pdf Last Modified 2/6/2014
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State of Tennessee Court - General Sessions (Must Be Completed) Civil Division County (Must Be Completed) KNOX File No. __________________ (Must Be Completed) Request to Postpone Filing Fees and Order (Uniform Civil Affidavit of Indigency) Division __________________ (Large Counties Only) Plaintiff _________________________________________________________________ (Name: First, Middle, Last of person/company that filed lawsuit) Defendant _______________________________________________________________ (Name: First, Middle, Last of the other person) If you cannot afford to pay the filing fees or costs at this time, fill out this form. And file it with your completed case documents. Even if the judge approves this form, you may have to pay court costs at the end of the case. Your Information Full Name: Address: street address Tel. (home): Birth date (mm/dd/yy): city (work): state (cell): zip Dependents List your dependents below. Name 1. Age Relationship 4. Name Age Relationship 2. 5. 3. 6. Employment: If you are working now, fill out below. If not working now, check here: Employer's name: Employer's address and tel. #: street address city state zip tel # How much do you earn after taxes are deducted? $ each (check one): week month Other: Request to Postpone Filing Fees and Order Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Other Income: List any other income that you get now or expect to get. How much do you get? $ $ $ $ / month / month / month / month Source of Income Unemployment Worker's Comp. Other* SSI $ $ $ $ How much do you get? / month / month / month / month Source of Income AFDC Social Security Retirement Disability __________________________________________________________ __________________________________________________________ Assets: List all assets that you own separately, with your spouse or with someone else: Fair Market ­ Money still = Value owed 1. Car, truck, or other vehicle $ 2. Other car, truck, or other vehicle 3. House, condominium, land 4. Other house, condominium, land List all bank/financial accounts below: Bank name 5. 6. 7. Cash Total: Other: $ $ $ $ Balance $ $ $ * Explain source of Other income here. Other: _________________________________________________________________________________________ Expenses: How much each month? Rent/House Payment $ Phone $ Groceries $ School Supplies $ How much each month? $ $ $ $ Gas Child Care Court-ordered Child Support Transportation Request to Postpone Filing Fees and Order American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 Electricity Clothing Water $ $ $ Medical/Dental Other Other $ $ $ Debts: Who do you owe? 1. 2. 3. $ $ $ How much do you owe? 4. 5. 6. Who do you owe? $ $ $ How much do you owe? I declare under penalty of perjury under the laws of the State of Tennessee that: · The information I have provided is true, correct, and complete. · I cannot afford to pay the filing fees at this time. Sign here: Date: Sworn and subscribed before me this _________ day of ______________________, 20_________. ________________________________________ Notary Public or Deputy Clerk _____________________________________ My Term Expires CATHERINE F SHANKS CLERK OF KNOX COUNTY GENERAL SESSIONS CIVIL DIVISION IMPORTANT! Take any proof that supports your case to the hearing, including: witnesses, photos, papers, receipts, etc. The court will not accept written statements from witnesses. The person must go to court in person. If you think a witness may not want to go to court, ask the clerk for subpoena forms. Complete the subpoena as soon as possible so the sheriff can serve them before court. The court and clerks are not allowed to give you legal advice, even if you don't have a lawyer. This form is a public record. It is not legal advice. The law may change and it is best to consult with a lawyer if possible. DO NOT FILL OUT THIS SECTION BELOW. THE JUDGE WILL FILL THIS SECTION OUT AT COURT. The court denies this Request because (judge will check all that apply): The applicant did not prove s/he cannot afford to pay costs associated with this case at this time. The applicant did not go to the court hearing for this case. This Request is dismissed. The applicant must pay court costs of: $ The court approves this Request and the applicant may file without paying the filing fees or costs at this time. Date: ____________________. NOTICE: Judge's signature: If the judge determines that you are not eligible to postpone filing fees, you have the right to a hearing before the judge. Or in cases that can be appealed to circuit court, a hearing before the circuit court judge. Request to Postpone Filing Fees and Order Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com
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