COURT COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : : Index No. Calendar No. IN THE CIRCUIT COURT OF TENNESSEE : JUDICIAL SUBPOENA Plaintiff(s) FOR THE THIRTIETH JUDICIAL DISTRICT, AT MEMPHIS -against- : UNIFORM CIVIL AFFIDAVIT OF INDIGENCY : In the Circuit Court of Shelby County, : Defendant(s) : . . Plaintiff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....... Docket # vs. THE PEOPLE OF THE STATE OF NEW YORK Defendant TO , having been duly sworn according to law, make oath that I, because of GREETINGS: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. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the1. Honorable name: at the Court Full located at County of in 2. room Address: on the , day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the 3. Telephone number: ( 4. Date of birth: ) 5. Names and ages of all dependents: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to (Name) (Age) the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Relationship Witness, Honorable Court in County, , one of the Relationship Justices of the day of , 20 Relationship Relationship (Attorney must sign above and type name below) 6. I am employed by: Attorney(s) for My employer's address is: My employer's telephone number is: ( 7. ) ext. Office and P.O. Address My present income, after federal income and social security taxes are deducted, is $ per week or $ Telephoneper month. No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : 8. Index No. Calendar No. I receive, or expect to receive, money from the following sources: : JUDICIAL SUBPOENA Plaintiff(s) AFDC -against- : per month beginning $ SSI $ Retirement $ Disability : : $ per month beginning per month beginning per month beginning Defendant(s) : . . . . . . . . . . . . . . Unemployment . . . . . . .$. . . . . . . . . . . . . . . . . . . . per month beginning ............. Worker's Comp $ per month beginning Other $ per month beginning $ per month Groceries GREETINGS: $ per month Electricity $ per month Medical/Dental $ per month THE PEOPLE OF THE STATE OF NEW YORK 9. TO My expenses are: Rent/house pymt WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court Water per month $ located at County of per monthin the in room Gas , on the day of $ , 20 , at o'clock noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this actionmonth part of the Transportation per on the $ Telephone to comply with this$subpoena is punishable asper month of court and will make you liable to Your failure a contempt the party School Supplies this subpoena was issued for a maximum penalty of $50 and all damages sustained as a on whose behalf per month $ result of your failure to comply. Clothing per month $ Witness, Honorable Child Care/ Court in 10. County, , one of the Justices of the day of Court-ordered Child Support $ Assets: per month (Attorney must sign above and type name below) Automobile $ Checking/Savings acct. $ House $ Other 11. , 20 $ My debts are: (Amount owed) (Fair market value) Attorney(s) for (Fair market value) Office and P.O. Address (To Whom) Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : Index No. : Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA : 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. : Defendant(s) : ...................................................... Plaintiff day of Sworn and subscribed before me this , 20 THE PEOPLE OF THE STATE OF NEW YORK Notary Public / D. C. TO My Commission expires: GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before ORDER ALLOWINGatFILING ON PAUPER'S OATH , the Honorable the Court County of appears, based on thelocated at of Indigency filed in this cause and after due inquiry made, that It Affidavit in room , on the day of , 20 , o'clock the Plaintiff is an indigent person and is qualified to file at this case on a in the oath. and at any recessed in pauper's noon, or adjourned date, to testify and give evidence as a witness in this action on the part of the It is so ordered this the day of , 20 Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Judge Witness, Honorable DETERMINATION OF NONINDIGENCY the Justices of the , one of Court in It appearing,County,upon the Affidavit of Indigency filed in this cause and after due inquiry day of , 20 based made, that the Plaintiff is not an indigent person because (Attorney must sign above and type name below) IT IS ORDERED AND ADJUDGED that the Plaintiff does not qualify for filing this case on a pauper's oath. Attorney(s) for This the day of , 20 Office and P.O. Address Judge Telephone No.: 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. Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com