Tennessee > Local County > Shelby > Chancery Court
Uniform Civil Affidavit Of Indigency - Tennessee
| Uniform Civil Affidavit Of Indigency Form. This is a Tennessee form and can be used in Chancery Court Shelby Local County . |
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IN THE CHANCERY COURT OF TENNESSEE FOR THE THIRTIETH JUDICIAL DISTRICT, AT MEMPHIS UNIFORM CIVIL AFFIDAVIT OF INDIGENCY In the Chancery Court of Shelby County, Plaintiff Docket # vs. Defendant I, , having been duly sworn according to law, make oath thatbecause of my poverty, I am unable to bear the expenses of this case and that I am justly entitled to the relief sought tothe 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 Relationship6. I am employed by: My employers address is: My employers telephone number is: 7. My present income, after federal income and social security taxes are deducted, is $ per week or $ per month.8. I 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 Comp per month beginning $ Other $ per month beginning9. My expenses are: Rent/house pymt. $ per month Groceries per month$ Electricity $ per month Water per month$ <<<<<<<<<********>>>>>>>>>>>>> 2 Gas per month $ Transportation $ per month Medical/Dental $ per month Telephone $ per month School supplies $ per month Clothing $ per month Child Care/ Court-ordered Child support $ per month 10. Assets: Automobile $ (Fair market value) Checking/ Savings Account $ House $ (Fair market value) 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. Plaintiff ORDER ALLOWING FILING ON PAUPERS OATH It appears, based on 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 this case on a paupers oath. It is so ordered this the day of , Chancellor 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 that the Plaintiff does not qualify for filing this case on a paupers oath. This the day of , Chancellor NOTICE: If the chancellor determines that based upon your affidavit you are not eligible to proceed under a paupersoath, you have the right to a hearing before the chancellor.
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