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_____________ Court ____________ County ____________ Tennessee

UNIFORM CIVIL AFFIDAVIT OF INDIGENCY
page 1 of 2

Case Number

_____________________________________________ vs. ____________________________________________

I, __________________________ , having been duly sworn according to law, make oath that because of my poverty, I am unable to bear the expenses of this case and that I am justly entitled to the relief sought to the best of my belief. The following facts support my poverty. 1. Full Name: 3. Telephone Number: 5. Names and Ages of All Dependents: __________________________________________ __________________________________________ ___________________________________________ ___________________________________________ 2. Address: 4. Date of Birth: Relationship: Relationship: Relationship: Relationship: __________________________________________ __________________________________________ __________________________________________ __________________________________________

6. I am employed by: _______________________________________________________________________________________ My employer's address is: ________________________________________________________________________________ My employer's phone number is: __________________________________________________________________________ 7. My Present income, after federal income and social security taxes, are deducted, is: $ ___________ 8. I receive or expect to receive money from the following sources: AFDC SSI Retirement Disability Unemployment Worker's Compensation Other 9. My expenses are: Rent/House Payment Groceries Electricity Water Gas Transportation 10. Assets: Automobile Checking/Savings Account House Other 11. My debts are:
Amount Owed To Whom

$ $ $ $ $ $ $ $ $ $ $ $ $

________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________

per month per month per month per month per month per month per month per month per month per month per month per month per month

beginning _________ beginning _________ beginning _________ beginning _________ beginning _________ beginning ________ beginning ________ Medical/Dental Telephone School Supplies Clothing Child Care or Court Ordered Child Support Other $ $ $ $ $ _______ _______ _______ _______ _______ per month per month per month per month per month

$ _______ per month

$ $ $ $

________ (FMV) ________ ________ (FMV) ________

__________________________________________________________ __________________________________________________________

______________________ ______________________ ______________________

__________________________________________________________________ __________________________________________________________________ __________________________________________________________________

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 PAUPER'S OATH It appears based upon 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 case upon a pauper's oath.

_____________ Court ____________ County ____________ Tennessee

UNIFORM CIVIL AFFIDAVIT OF INDIGENCY
page 2 of 2

Case Number

_____________________________________________ vs. ____________________________________________

It is so ordered this the ________day of ________, 20____ _______________________________________________________________

JUDGE DETERMINATION OF NONINDIGENCY 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 AJUDGED that the Plaintiff does not qualify for filing this case on a pauper's oath. This the ____ day of ____________ , 20 __________ . _______________________________________________________ JUDGE

NOTICE: If the judge determines that based upon your affidavit you are not eligible to proceed under a pauper's oath, you have the right to a hearing before the judge or, in those cases that can be appealed to Circuit Court, a hearing before the Circuit Court judge.