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Uniform Affidavit Of Indigency (Interlock Ignition) - Tennessee

Uniform Affidavit Of Indigency (Interlock Ignition) Form. This is a Tennessee form and can be used in Appellate .
 Fillable pdf Last Modified 7/15/2014
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IN THE ______________________ COURT FOR ______________________ COUNTY STATE OF TENNESSEE vs. ______________________ Defendant UNIFORM AFFIDAVIT OF INDIGENCY FOR PURPOSES OF INTERLOCK ASSISTANCE FUND Comes the defendant and, subject to the penalty of perjury, makes oath to the following facts (please list, circle, complete, etc.): 1. 2. 3. 4. 5. 6. 7. Full name: ______________________ List any other names you have used: ___________________________ Birthdate: _______________________ Address: ______________________________________________________ Telephone Nos.: (Home/Cell) ___________________________ (Work) _______________________________ Are you working ? ( ) Yes ( ) No If so, where? ________________________________________________ How much money do you make? $ _________________ per hour/day/week/month/year (circle one) Do you have any income other than the income listed above? ( ) Yes ( ) No If so, list the sources, payment periods, and amounts below. Possible sources include, but are not limited to, interest, gifts, AFDC, SSI, social security, retirement, disability, pension, unemployment, alimony, and workers' compensation. Case No. ______________________ $______________________ per ______________________ from _______________________________________ $______________________ per ______________________ from _______________________________________ $______________________ per ______________________ from _______________________________________ $______________________ per ______________________ from _______________________________________ $______________________ per ______________________ from _______________________________________ 8. Acknowledging that I am still under oath, I certify that I have listed above all income I receive. 9. By signing this form, I agree to file a copy of my most recent income tax return if requested by the court. 10. I understand that it is a Class A misdemeanor for which I can be sentenced to jail for up to 11 months, 29 days or be fined up to $2,500, or both, if I intentionally misrepresent, falsify or withhold any information required in this affidavit. I also understand that I may be required by the Court to produce other information in support of my request to be declared indigent for purposes of using the Interlock Assistance Fund. This ________ day of ___________________, 20___________. ____________________________________. Defendant Sworn to and Subscribed before me this ________ day of ___________________________, 20____________. _________________________________ Clerk ________________________________ Judge I hereby find that the above-named defendant receives an annual income, after taxes, of 185% or less of the poverty guidelines updated periodically in the federal register by the United States Department of Health and Human Services under the authority of 42 U.S.C. ยง 9902(2), and that the defendant is therefore indigent and financially unable to pay for a functioning ignition interlock device. ________________________ Judge ****** The defendant must submit a copy of this form to the interlock provider before installation of the ignition interlock device, and the interlock provider must submit a copy of this form to the State Treasurer prior to being reimbursed. To locate a Tennessee Department of Safety certified Ignition Interlock Device Installer, go to http://www.tn.gov/safety/FinancialResponsibility/IIDInstall.htm or call the Department of Safety at (615) 743-4960. Ignition Interlock Device Installers may contact the Tennessee Department of Treasury at (615) 741-1337 or email Interlock.Assistance@tn.gov for further information regarding reimbursement from the Interlock Assistance Fund. Rev. 7/11 Authority: TCA 55-10-421 American LegalNet, Inc. www.FormsWorkFlow.com
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