Free Prisoner Account Statement--MUST be filed with Application to Proceed in Forma Pauperis  - Tennessee

CERTIFICATE TO BE COMPLETED BY AN AUTHORIZED CUSTODIAN OF INMATE ACCOUNTS I certify that the applicant herein has the sum of $ at the on account to his/her credit (institution where the

applicant is currently incarcerated). I further certify that the average balance in the applicant's trust fund account during the last six months was $ . A copy of the applicant's

trust fund account (or an institutional equivalent) for the last six months is attached hereto.

Signature of Authorized Officer

Sworn to and subscribed before me this day of ,2 .

Notary Public My commission expires .