Uniform Affidavit Of Indigency Rule 13

____________ Court UNIFORM AFFIDAVIT OF Case Number: _____________ County INDIGENCY RULE 13 _______________ Tennessee Page 1 of 2 State of Tennessee vs. _____________________________________________________ Part I 1. Full Name: _________________________________________ 2. Social Security No.: _______________________________ 3. Any other names ever used: ____________________________ 4. Address:_________________________________________ 5. Telephone Nos.: Home ( )_________________________ Work ( )____________________ Other ( )________________ 6. Are you working anywhere? Yes No If yes, where?________________________________________________________ 7. How much do you make? $_____________________________________ Weekly Monthly Etc. 8. Birthday: Month ______________________ Day _______________ Year ________________ 9. Do you receive any governmntal assistance or pensions (de isability, SSI, AFDC, etc.)? Yes No What is its value $____________________ Month: _____________ Day:____________ Year:_______________ 10. Do you own any property (house, car, bank account, etc.)? Yes No Whatis its value? $________________________________________ 11. Are you, or your family, going to be able to post your bond? Yes No 12. Are you, or your family, going to hire a private attorney? Yes No 13. Are you now in custody? Yes No If so, how long have you been in custody? _______________________ (If the defendant is in custody, unable to make bond and the answers to questions one (1) through eleven (11) make it cleart the defendant has no r thaesources to hire a private attorney, skip Part II and complete Part III. If Part II is to be completed, do not list items already listed in Part I.) PART II 14. Names and ages of all dependents: ______________________ Relationship: _______________________________ ___________________________________________________ Relationship: _______________________________ ___________________________________________________ Relationship: _______________________________ 15. I have met with following lawyer(s), have attempted to sai hired lawyer(s) to represent me, and have been unable to do so: Name: _____________________________________________ ___________________________________________ Address: ____________________________________________ ___________________________________________ 16. All of my income from all sources (including, but not limited to wages, interest, gifts, AFDC, SSI, social securitemy, retent, ir disability, pension, unemployment, alimony, workers compensation, etc.): $_______________________ per _________________________ from ______________________________________ $_______________________ per _________________________ from ______________________________________ $_______________________ per _________________________ from ______________________________________ 17. All money available to me from any source: A. Cash _____________________ B. Checking, Savings, or CD Account(s) give bank, account no., balance _______________________________________ C. Debts ed mow e _______________________________________________________________________ _____________ D. Credit Card(s) give account no., balance, credit limit, and type (Visa, MasterCard, American Express, etc.) ________________________________________________________________________ ____________________________ 18. All vehicles/vessels owned by me, solely or jointly, within the last six months (including but not limited to cars, t, rucks motorcycles, farm equip., boats, etc.): __________________________________________________ Value: $_______________ Amt. Owed $________________ __________________________________________________ Value: $_______________ Amt. Owed $________________ __________________________________________________ Value: $_______________ Amt. Owed $ ________________ <<<<<<<<<********>>>>>>>>>>>>> 2 ____________ Court Case Number: _____________ County UNIFORM AFFIDAVIT OF INDIGENCY _______________ Tennessee Page 2 of 2 State of Tennessee vs. _____________________________________________________ 19. All real estate owned by me, solely or jointly, within the last six months) including land, lots, houses, mobile homc.): es, et _________________________________________________ Value: $________________ Amt. Owed $________________ _________________________________________________ Value: $________________ Amt. Owed $________________ 20. All assets or property not already listed owned within the last six months or expected in the future: _________________________________________________ Value: $________________ Amt. Owed $________________ _________________________________________________ Value: $________________ Amt. Owed $________________ 21. The last income tax return I filed was for the year ___________ and it reflected a net income of $_________________________. I will file a copy of same within one week if required. 22. I am out of jail on bond of $ _________________________ Made by __________________________________________ The money tmo ake bond, $_________________________ was paid by ________________________________________ PART III 23. Acknowledging that I am still under oath, I certify that I have listed in Parts I and II all assets in which I hold or expect to hold any legal or equitable interest. 24. I am financially unable to obtain the assistance of a lawyer and request the court to appoint a lawyer for me. 25. I understand thatit 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 $2500 or botif I intentioh nally or knowingly misrepresent, falsify, or withhold any information required in this affidavit. I also understand that I may be required by the Ctoourt produce ot her information in support of my request for an attoneyr . Date: _______________________________ ______________________________________ ____________ D efendants Signature Sworn to and subscribed before me this day: ________________________________________ __________________________________________________ Clerk/Deputy Clerk Circuit Court __________________________________________________ Circuit Criminal Court Judge