Affidavit Of Inmate Pursuant To TCA Section 41-21-801 Et Seq {003}

IN THE CHANCERY COURT OF HAMILTON COUNTY, TENNESSEE * __________________________________________, * Petitioner * CASE N0.__________ vs. * PART______ __________________________________________, * R espondent * AFFIDAVIT OF INMATE PURSUANT TO T.C.A. 41-21-801, et seq. 1. Full Name:________________________________________________________________ 2. Date of Birth:__________________ 3. Address:__________________________________________________________________________________________________ 4. Telephone Number: ________________________ 5. Tennessee Department of Correction Inmate N0.______________________ 6. Provide the following information for all lawsuits or claims ever filed regardless of whether or not you were incarcheern tatehde w lawsuit or claim occurred.L a wsuits or claims you have filed under any other name must also be listed. All parts of Question 6 must be answered as to each lawsuit or claim you have previously filed. Attach additional sheecesets ifsa nry. 6.1 Case Name:___________________________________________________________ 6.2 Case Number:____________________ 6.3 Name & Location of Court in which lawsuit or claim was filed:_____________________________________________________ 6.4 The operative facts for which relief was sought in the lawsuit or claim:_______________________________________________ ___________________________________________________________________________________________________________ 6.5 The legal theory on which the relief sought was based:____________________________________________________________ ___________________________________________________________________________________________________________ 6.6 Identification of each party named in the lawsuit or claim:_________________________________________________________ ___________________________________________________________________________________________________________ 6.7 The final result of the lawsuit or claim:________________________________________________________________________ ___________________________________________________________________________________________________________ 6.8 Was the lawsuit or claim dismissed as either frivolous or malicio
usY? ES
NO 6.8.1 If YES, state the date of the final order affirming the dismissal:___________________________________________________ 7. A current,cer tified copy of your inmate trust account statement must be attached. I s it?
YES
NO 8. Was this claim subject to review by a grievance committee established by the Tennessee Department of Correction?
YES
NO 8.1 State the date the claim wafiles d with the grievance committee:____________________________________________________ 8.2 State the date you received a decision from a grievance committee:__________________________________________________ 8.3 A copy of the final decision from the grievance committee must be attached. Is it?
Y ES
NO [Form 003, Rev. 2000.12.29] 1<<<<<<<<<********>>>>>>>>>>>>> 2I hereby declare under penalty of perjury that the forgoing answers are true, correct and complete. ____________________________________ A FFIANT STATE OF TENNESSEE ) COUNTY OF ________________ ) Sworn to and subscribed to before me this ____ day of _________, 20___. ____________________________________ My Commission Expires:___________ NOTARY PUBLIC OPTIONAL PAGE FOR ADDITIONAL INFORMATION 6. Provide the following information for all lawsuits or claims ever filed regardless of whether or not you were incarcheern tatehde w lawsuit or claim occurred.L a wsuits or claims you have filed under any other name must also be listed. All parts of Question 6 must be answered as to each lawsuit or claim you have previously filed. Attach additional sheecesets ifsa nry. 6.1 Case Name:__________________________________________________ 6.2 Case Number:_____________________________ 6.3 Name & Location of Court in which lawsuit or claim was filed:_____________________________________________________ 6.4 The operative facts for which relief was sought in the lawsuit or claim:_______________________________________________ ___________________________________________________________________________________________________________ 6.5 The legal theory on which the relief sought was based:____________________________________________________________ ___________________________________________________________________________________________________________ 6.6 Identification of each party named in the lawsuit or claim:_________________________________________________________ ___________________________________________________________________________________________________________ 6.7 The final result of the lawsuit or claim:________________________________________________________________________ ___________________________________________________________________________________________________________ 6.8 Was the lawsuit or claim dismissed as either frivolous or malicio
usY? ES
NO 6.8.1 If YES, state the date of the final order affirming the dismissal:___________________________________________________ 7. A current copy of your inmate trust account statement must be attached . Is
it?YES
NO 8. Was this claim subject to review by a grievance committee established by the Tennessee Department of Correction?
YES
NO 8.1 State the date the claim wafiles d with the grievance committee:____________________________________________________ 8.2 State the date you received a decision from a grievance committee:__________________________________________________ 8.3 A copy of the final decision from the grievance committee must be attached. Is it?
Y ES
NO [Form 003, Rev. 2000.12.29] 2