Request to Postpone Filing Fees and Order Page 1 of 3 If you cannot afford to pay the filing fees or costs at this time, fill out this form. And file it with your completed case documents. Even if the judge approves this form, you may have to pay court costs at the end of the case. Your Information Full Name: Address: street address city state zip Tel. (home): (work): (cell): Birth date (mm/dd/yy): Dependents List your dependents below. Name Age Relationship Name Age Relationship 1. 4. 2. 5. 3. 6. Employment: If you are working now, fill out below. If not working now, check here: Employer222s name: Employer222s address and tel. #: street address city state zip tel # How much do you earn after taxes are deducted? $ each (check one): week month Other: State of Tennessee Court (Must Be Completed) County (Must Be Completed) Request to Postpone Filing Fees and Order (Uniform Civil Affidavit of Indigency) File No. (Must Be Completed) Division (Large Counties Only) Plaintiff (Name: First, Middle, Last of person/company that filed lawsuit) Defendant (Name: First, Middle, Last of the other person) American LegalNet, Inc. www.FormsWorkFlow.com Request to Postpone Filing Fees and Order Page 2 of 3 Other Income: List any other income that you get now or expect to get. Source of Income How much do you get? Source of Income How much do you get? AFDC $ / month Unemployment $ / month Social Security $ / month Worker222s Comp. $ / month Retirement $ / month Other* $ / month Disability $ / month SSI $ / month * Explain source of Other income here. Other: Assets: List all assets that you own separately, with your spouse or with someone else: Fair Market Value 226 Money still owed = 1. Car, truck, or other vehicle $ 2. Other car, truck, or other vehicle $ 3. House, condominium, land $ 4. Other house, condominium, land $ List all bank/financial accounts below: Bank name Balance 5. $ 6. $ 7. Cash $ Total: $ Other: Expenses: How much each month? How much each month? Rent/House Payment $ Gas $ Phone $ Child Care $ Groceries $ Court - ordered Child Support $ School Supplies $ Transportation $ American LegalNet, Inc. www.FormsWorkFlow.com Request to Postpone Filing Fees and Order Page 3 of 3 Electricity $ Medical/Dental $ Clothing $ Other $ Water $ Other $ Debts: Who do you owe? How much do you owe? Who do you owe? How much do you owe? 1. $ 4. $ 2. $ 5. $ 3. $ 6. $ I declare under penalty of perjury under the laws of the State of Tennessee that: The information I have provided is true, correct, and complete. I cannot afford to pay the filing fees at this time. Sign here: Date: Sworn and subscribed before me this day of , 20. Notary Public or Deputy Clerk My Term Expires IMPORTANT! Take any proof that supports your case to the hearing, including: witnesses, photos, papers, receipts, etc. The court will not accept written statements from witnesses. The person must go to court in person. If you think a witness may not want to go to court, ask the clerk for subpoena forms. Complete the subpoena as soon as possible so the sheriff can serve them before court. The court and clerks are not allowed to give you legal advice, even if you don222t have a lawyer. This form is a public record. It is not legal advice. The law may change and it is best to consult with a lawyer if possible. DO NOT FILL OUT THIS SECTION BELOW. THE JUDGE WILL FILL THIS SECTION OUT AT COURT. The court denies this Request because (judge will check all that apply): The applicant did not prove s/he cannot afford to pay costs associated with this case at this time. The applicant did not go to the court hearing for this case. This Request is dismissed. The applicant must pay court costs of: $ The court approves this Request and the applicant may file without paying the filing fees or costs at this time. Judge222s signature: Date: . NOTICE: If the judge determines that you are not eligible to postpone filing fees, you have the right to a hearing before the judge. Or in cases that can be appealed to circuit court, a hearing before the circuit court judge. American LegalNet, Inc. www.FormsWorkFlow.com