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Paupers Oath Affidavit And Order - Tennessee

Paupers Oath Affidavit And Order Form. This is a Tennessee form and can be used in Circuit Court Davidson Local County .
 Fillable pdf Last Modified 2/10/2014
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In the Circuit Court of Davidson County, Tennessee Plaintiff/Petitioner VS. Case No. Defendant/Respondent UNIFORM CIVIL AFFIDAVIT OF INDIGENCY I, __________________________, having been duly sworn according to law, make oath that because of my poverty, I am unable to bear the expenses of this case and that I am justly entitled to the relief sought to the best of my belief. The following facts support my poverty: 1. Full Name: _______________________________________________________________ 2. Address: _________________________________________________________________ 3. Telephone Number: ________________________________________________________ 4. Date of Birth: ______________________________________________________________ 5. Names and Ages of All Dependents: ______________________________________________ Relationship _______________________ ______________________________________________ Relationship _______________________ ______________________________________________ Relationship _______________________ ______________________________________________ Relationship _______________________ 6. I am employed by: ______________________________________________________________ My employer's address is: _____________________________________________________ My employer's telephone number is: _____________________________________________ 7. My present income, after federal income and social security taxes, are deducted, is: $_______________ 8. I receive or expect to receive money from the following sources: AFDC SSI Retirement Disability Unemployment $____________ per month beginning __________________ $____________ per month beginning __________________ $____________ per month beginning __________________ $____________ per month beginning __________________ $____________ per month beginning __________________ American LegalNet, Inc. www.FormsWorkFlow.com Worker's Compensation Other 9. My expenses are: Rent/House Payment Groceries Electricity Water Gas Transportation Medical/Dental Telephone School Supplies Clothing $____________ per month beginning __________________ $____________ per month beginning __________________ $___________________ per month $___________________ per month $___________________ per month $___________________ per month $___________________ per month $___________________ per month $___________________ per month $___________________ per month $___________________ per month $___________________ per month $___________________ per month $___________________ per month Child Care or Court Ordered Child Support Other 10. Assets: Automobile Checking/Savings Account House Other 11. My debts are: Amount Owed $__________ (Fair Market Value)____________ $___________________ $__________ (Fair Market Value)____________ $____________________ To Whom I hereby declare under the penalty of perjury that the foregoing answers are true, correct, and complete and that I am financially unable to pay the costs of this action. ______________________________ PLAINTIFF/PETITIONER Sworn and subscribed before me this _______ day of ____________________________, 20_______. _________________________________________ Notary Public or Deputy Clerk American LegalNet, Inc. www.FormsWorkFlow.com In the Circuit Court of Davidson County, Tennessee Plaintiff/Petitioner VS. Case No. Defendant/Respondent ORDER ALLOWING FILING ON PAUPER'S OATH IT APPEARS BASED UPON THE AFFIDAVIT OF INDIGENCY FILED IN THIS CAUSE AND AFTER DUE INQUIRY MADE THAT THE PLAINTIFF IS AN INDIGENT PERSON AND IS QUALIFIED TO FILE CASE UPON A PAUPER'S OATH. IT IS SO ORDERED THIS THE ______ DAY OF ___________________, 20_____. ________________________________ JUDGE DETERMINATION OF NON-INDIGENCY IT APPEARING BASED UPON THE AFFIDAVIT OF INDIGENCY FILED IN THIS CAUSE AND AFTER DUE INQUIRY MADE THAT THE PLAINTIFF IS NOT AN INDIGENT PERSON BECAUSE: ____________________________________________________________________________________ ____________________________________________________________________________________ IT IS ORDERED AND ADJUDGED FILING THIS CASE ON A PAUPER'S OATH. THAT THE PLAINTIFF DOES NOT QUALIFY FOR THIS THE ______ DAY OF ___________________, 20_____. ________________________________ JUDGE NOTICE: IF THE JUDGE DETERMINES THAT BASED UPON YOUR AFFIDAVIT YOU ARE NOT ELIGIBLE TO PROCEED UNDER A PAUPER'S OATH, YOU HAVE THE RIGHT TO A HEARING BEFORE THE JUDGE OR, IN THOSE CASES THAT CAN BE APPEALED TO CIRCUIT COURT, A HEARING BEFORE THE CIRCUIT COURT JUDGE. American LegalNet, Inc. www.FormsWorkFlow.com
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