In the Circuit Court of Davidson County, Tennessee Plaintiff/Petitioner vs. Case No. Defendant/Respondent 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 case and I am justly entitled to the relief sought to the best of my belief. By direction of the Davidson County Judges, you are required to attach to this Affidavit documentation of your income (employee paystubs, W-2 forms, 1099 forms), documentation of unemployment benefits which you are currently receiving, or documentation of the fact that your unemployment benefits have ceased. In addition, you are required to attach to this Affidavit documents which support your listed monthly living expenses. The following facts support my poverty: 1. Full Name: 2. Address: 3. Telephone Number: 4. Date of Birth: 5. Names and Ages of All Dependents: Relationship Relationship Relationship Relationship 6. I am employed by: My employer222s address is: My employer222s telephone 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: $ per month, beginning SSI: $ per month, beginning Retirement: $ per month, beginning Disability: $ per month, beginning Rev. 6/11/14 American LegalNet, Inc. www.FormsWorkFlow.com Unemployment:$ per month, beginning Worker222s Compensation: $ per month, beginning Other: $ per month, beginning 9. My expenses are: Rent/House Payment ................................................. $ per month Groceries .................................................................... $ per month Electricity .................................................................... $ per month Water .......................................................................... $ per month Gas ............................................................................. $ per month Transportation ............................................................ $ per month Medical/Dental ............................................................ $ per month Telephone ................................................................... $ per month School Supplies .......................................................... $ per month Clothing ...................................................................... $ per month Child Care or Court-Ordered Child Support ............... $ per month Other: ...... $ per month Other: ...... $ per month 10. Assets: Automobile ...............................................$ (Fair Market Value)$ Checking/Savings Account ...................... $ Checking/Savings Account ...................... $ House ...................................................... $ (Fair Market Value) $ Other: ..... $ 11. My debts are: Amount Owed To Whom $ $ $ 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/PETITIONER Sworn to and subscribed before me on Notary Public or Deputy Clerk To Request an ADA accommodation, please contact Dart Gore at (615) 880-3309 Rev. 6/11/14 American LegalNet, Inc. www.FormsWorkFlow.com In the Circuit Court of Davidson County, Tennessee Plaintiff/Petitioner vs. Case No. Defendant/Respondent ORDER ALLOWING FILING ON PAUPER222S OATH It appears, based upon the Affidavit of Indigency filed in this cause and after due inquiry made, that the Plaintiff/Petitioner is an indigent person and is qualified to file this case upon a pauper222s oath. IT IS SO ORDERED. JUDGE DETERMINATION OF NON-INDIGENCY It appears, based upon the Affidavit of Indigency filed in this cause and after due inquiry made, that the Plaintiff/Petitioner is not an indigent person because: IT IS SO ORDERED AND ADJUDGED that the Plaintiff/Petitioner does not qualify for filing this case on a pauper222s oath. JUDGENOTICE : IF THE JUDGE DETERMINES THAT BASED UPON YOUR AFFIDAVIT, YOU ARE NOT ELIGIBLE TO PROCEED UNDER A PAUPER222S 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. To Request an ADA accommodation, please contact Dart Gore at (615) 880-3309 Rev. 6/11/14Entered on Entered on American LegalNet, Inc. www.FormsWorkFlow.com