UNIFORM CIVIL AFFIDAVIT OF INDIGENCY IN THE CHANCERY COURT OF HAMILTON COUNTY, TENNESSEE T.C.A. § 20-12-127, Tenn. Sup. Ct. R 29. DEFENDANT PLAINTIFF PART 1 PART 2 ACTION N0. I, _____________________________________________, do solemnly swear under penalties of perjury, that I am a resident of Tennessee, and that owing to my poverty, I am unable to bear the expenses of the action which I am about to commence, 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 2. Address 4. Date & Place of Birth Name Age Relation 5. Names & Ages Name Age Relation of Name Age Relation All Dependents Name Age Relation Employer Employer’s Address Employer’s Phone Number 6. I am employed by 7. My present income, from all sources, after federal income/social security taxes are deducted, is 8. I receive or expect to receive money from the following: SSI $ per month beginning Retirement Other $ $ Unemployment per month beginning Worker’s comp per month beginning Disability Rent/House Pmt Groceries 9. My expenses are $ AFDC Electricity Water Other (identify) 10. My assets are (Fair Market Value) $ $ $ $ per month Gas per month Transportation per month Medical/Dental per month Telephone Automobile $ Owed to House $ per week $ $ $ $ $ per month per month beginning per month beginning per month beginning per month beginning $ $ $ $ per month School Supplies $ per month per month Clothing $ $ $ $ per month per month Child Care per month Child Support Checking/Savings Account Reason for debt $ per month per month per month Other $ $ Owed to Reason for debt $ 11. My debts are Owed to Reason for debt $ Owed to Reason for debt $ NOTICE: filing under a pauper's oath without giving security for costs and without payment of litigation taxes due does not relieve you from responsibility for the costs and taxes but suspends their collection until taxed by the court. T.C.A. §20-12-127(b). I hereby further 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 SIGNATURE Sworn to and subscribed before me this day of 20 DEPUTY CLERK DETERMINATION OF INDIGENCY It appears based upon this affidavit filed in this action, and after due inquiry made, that the PLAINTIFF: is an indigent resident of Tennessee and is qualified to file this case on a pauper’s oath. is not an indigent person eligible to file upon a pauper’s oath because: THIS _____ DAY OF ________________, 20____. _________________________________ CLERK & MASTER NOTICE: IF THE COURT 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 CHANCELLOR. Page 1 of 1 page. UNIFORM AFFIDAVIT OF INDIGENCY Form 086E, Rev. 2009.02.07 American LegalNet, Inc. www.FormsWorkFlow.com