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Uniform Civil Affidavit Of Indigency - Tennessee
| Uniform Civil Affidavit Of Indigency Form. This is a Tennessee form and can be used in Circuit Court Shelby Local County . |
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IN THE CIRCUIT COURT OF TENNESSEE FOR THE THIRTIETH JUDICIAL DISTRICT, AT MEMPHIS UNIFORM CIVIL AFFIDAVIT OF INDIGENCY In the Circuit Court of Shelby County, Plaintiff vs. Docket # 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 therelief 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: (Name) (Age) Relationship Relationship Relationship Relationship6. I am employed by: My employers address is: My employers telephone number is(): ext.7. My present income, after federal i ncome and social security taxes are deducted, is $ per week or $ per month.<<<<<<<<<********>>>>>>>>>>>>> 28. 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 pym t $ per month Groceries $ per month Electricity $ per month Water $ per month Gas $ per month Transporta tion $ 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 acct. $ House $ (Fair market value) Other $ 11. My debts are: (Amount owed) (To Whom)<<<<<<<<<********>>>>>>>>>>>>> 3I hereby declare, under the penalty of perjury, that the foregoing answers are true, correct and completeand that I am financially unable to pay the costs of this action. Plaintiff Sworn and subscribed before me this day of , 20 Notary Public / D. C.My Commission expires: OR DER ALLOWI NG FILING ON PAUPER S OATH It appears, based on the Affidavit of Indigency filed in this cause and after due inquiry made, thatthe Plaintiff is an indigent person and is qualified to file in this case on a paupers oath. It is so ordered this the day of , 20 Judge D ETER MINATION OF N ONINDIGENCY It appearing, based upon the Affidavit of Indigency filed in this cause and after due inquirymade, 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 apaupers oath. This the day of , 20 Judge NOTICE: If the Judge determines that based upon your affidavit you are not eligible to proceed under apaupers oath, you have the right to a hearing before the Judge.
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