General Sessions Court Madison County Jackson, Tennessee U NIFORM C IVIL AFFIDAVIT OF INDIGENCY page 1 of 2 Case Number vs. 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 that I am justly entitled to the relief sought to the best of my belief. 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 phone 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 Unemployment $ per month beginning Worker222s Compensation $ per month beginning Other $ per month beginning 9. My expenses are: Rent/House Payment $ per month Medical/Dental $ per month Groceries $ per month Telephone $ per month Electricity $ per month School Supplies $ per month Water $ per month Clothing $ per month Gas $ per month Child Care or $ per month Transportation $ per month Court Ordered Child Support Other $ per month 10. Assets: Automobile $ (FMV) Checking/Savings Account $ House $ (FMV) 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 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 is an indigent person and is qualified to file case upon a pauper222s oath. American LegalNet, Inc. www.FormsWorkFlow.com General Sessions Court Madison County Jackson, Tennessee U NIFORM C IVIL AFFIDAVIT OF INDIGENCY page 2 of 2 Case Number vs. It is so ordered this the day of , 20 JUDGE DETERMINATION OF NONINDIGENCY It appearing based upon the Affidavit of Indigency filed in this cause and after due inquiry made that the Plaintiff is not an indigent person because . IT IS ORDERED AND AJUDGED that the Plaintiff does not qualify for filing this case on a pauper222s oath. This the day of , 20 . JUDGE NOTICE: 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. American LegalNet, Inc. www.FormsWorkFlow.com