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Uniform Civil Affidavit Of Indigency (Print Double Sided Onto One Sheet) - Tennessee
| Uniform Civil Affidavit Of Indigency (Print Double Sided Onto One Sheet) Form. This is a Tennessee form and can be used in Chancery Court Davidson Local County . |
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IN THE CHANCERY COURT FOR DAVIDSON COUNTY, TENNESSEE TWENTIETH JUDICIAL DISTRICT _________________________________________ ) (PLAINTIFF) ) ) VS. ) CASE NO. ____________________ ) _________________________________________ ) (DEFENDANT) 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 cause 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: __________________________________________________________ 7. My present weekly take-home pay is: $__________________________________________ 8. I am not employed, but receive or expect to receive money from the following sources: AFDC $__________ per month beginning ________________ SSI $__________ per month beginning ________________ Retirement $__________ per month beginning ________________ Disability $__________ per month beginning ________________ Unemployment $__________ per month beginning ________________ Workers Compensation $__________ per month beginning ________________ Other $__________ per month beginning ________________ 9. My expenses are: Rent/House Payment $ _______________________________ per month Groceries $ _______________________________ per month Electricity $ _______________________________ per month <<<<<<<<<********>>>>>>>>>>>>> 2 Water $ _______________________________ per month Gas $ _______________________________ per month Transportation $ _______________________________ per month Medical $ _______________________________ per month Telephone $ _______________________________ per month Other $ _______________________________ per month 10. Assets: Automobile: $ _______________________________ Checking/Savings Account $ _______________________________ House $ _______________________________ Other $ _______________________________ 11. My Debts are: Amount Owed 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. ________________________________ P LAINTIFF
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