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Uniform Civil Affidavit Of Indigency (Print Double Sided Onto One Sheet) Form. This is a Tennessee form and can be use in Davidson Local County.
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Tags: Uniform Civil Affidavit Of Indigency (Print Double Sided Onto One Sheet), Tennessee Local County, Davidson
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
IN THE CHANCERY COURT FOR DAVIDSON:COUNTY, TENNESSEE
Calendar No.
TWENTIETH JUDICIAL DISTRICT
_________________________________________
(PLAINTIFF)
-againstVS.
_________________________________________
(DEFENDANT)
Plaintiff(s)
)
)
)
)
)
)
:
JUDICIAL SUBPOENA
:
CASE NO. ____________________
:
:
Defendant(s)
:
. . . . . . . . . . . . . . . . . . . . . . . . .UNIFORM.CIVIL .AFFIDAVIT. OF.INDIGENCY
........ ..... ......... .. .
I, _____________________________________________, having been duly sworn according to law, make oath that
because of my poverty, I am unable to bear the expenses of this cause and that I am justly entitled to the relief sought to the
best of my belief. The following facts support my poverty.
THE PEOPLE OF THE STATE OF NEW YORK
1.
2.
3.
Full Name:
_____________________________________________________________________________
Address:
TO
_____________________________________________________________________________
Telephone Number: _______________________________ 4. Date of Birth: ______________________________
GREETINGS:
5.
Names and Ages of All Dependents:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
_______________________________________ Relationship ________________________
,
the Honorable
at the
Court
located at
County of
_______________________________________ Relationshipat
in room
, on the
day of
, 20
, ________________________ noon, and at any recessed
o'clock in the
or adjourned date, to testify and give evidence as a witness in this action on the part of the
_______________________________________ Relationship ________________________
_______________________________________ Relationship ________________________
I am Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
employed by: __________________________________________________________
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
7. result of present weekly take-home pay is: $__________________________________________
My your failure to comply.
6.
8.
I am not employed, but receive or expect to receive money from the following sources: the Justices of the
Witness, Honorable
, one of
Court in
AFDC
County,
day of
, 20
$__________ per month beginning ________________
SSI
Retirement
$__________ per month beginning ________________
Disability
$__________ per month beginning ________________
Unemployment
$__________ per month beginning ________________
Worker’s Compensation
$__________ per month beginning ________________
Other
9.
$__________ per month beginning ________________
$__________ per month beginning ________________
Office and P.O. Address
(Attorney must sign above and type name below)
Attorney(s) for
My expenses are:
Rent/House Payment
Groceries
Electricity
$ _______________________________ per month
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
$ _______________________________ per month
$ _______________________________ per month
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
Water
:
$ _______________________________ per month
Calendar No.
Gas
$ _______________________________ per month
:
JUDICIAL SUBPOENA
Plaintiff(s)
Transportation
-against- $ _______________________________ per month
:
Medical
$ _______________________________ per month
Telephone
$ _______________________________ per month
Other
$ _______________________________ per month
:
:
Defendant(s)
:
. 10.. . . . .Assets: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..
.....
Automobile:
$ _______________________________
THE PEOPLE OF THE STATE OF NEW YORK
Checking/Savings Account
$ _______________________________
11.
House
$ _______________________________
Other
TO
$ _______________________________
My Debts are:
GREETINGS:
Amount Owed
To Whom
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
___________________________________________________________________________________________
located at
County of
in room _______________________________________________________________________________________recessed
, on the
day of
, 20
, at
o'clock in the
noon, and at any
or adjourned date, to testify and give evidence as a witness in this action on the part of the
________________________________________________________________________________________
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.
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.
________________________________
PLAINTIFF
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name below)
Attorney(s) for
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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