_____________ Court ____________ County ____________ Tennessee AFFIDAVIT OF INCOME AND PROPERTY Case Number _____________________________________________ vs. _______________________________________________ Comes now the Defendant(s) and, subject to the penalty of perjury, makes oath and says that the following facts are true and that there is NO OTHER source of income or property other than that described below: 7. List all land/house/real estate/property you own: 1. Full name: DESCRIBE VALUE Address: $ Phone # $ Soc. Sec. No. $ Employer: $ Phone # 8. List all personal property/cars/trucks/ 2. List all dependents: furniture/stocks/bonds/tools/equipment you own and its total Name Age Relationship value: DESCRIBE VALUE Cars $ Trucks $ Other $ $ 3. List all income from any source: $ $ per/wk /mo , $ from : $ from $ from per/wk /mo , : per/wk /mo , : I receive CHILD SUPPORT in the sum of $ per 4. List all bank accounts: ACCOUNT BANK/SOURCE Checking Savings Other: Other: 5. List all debts: CREDITOR/ADDRESS 6. List all monthly household expenses: Rent/Mortgage: Utilities: Health Insurance: Transportation Cost: Food: Clothing: Other: TOTAL . BALANCE $ $ $ $ BALANCE $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 9. List all assets/property sold or transferred in the last six months: DESCRIBE VALUE $ $ $ $ $ 10. The last income tax I filed was for and it reflected an income of $ and I attach a copy hereto or will file the same within seven days. LIST ALL PROPERTY YOU CLAIM TO BE EXEMPT PURSUANT TO LAW: All clothing for myself and my family; all receptacles for said clothing; family portraits; family Bible; school books; and VERIFICATION AND OATH: Comes now the Petitioner(s) / Defendant(s) and makes oath, subject to the penalty of perjury, that the information in this Motion for Installment Payment is true to the best of Petitioner's knowledge, information and belief. Defendant(s) Sworn to and subscribed before me on ____________________ Clerk/Deputy Clerk/Notary Public Commission Expires: American LegalNet, Inc. www.USCourtForms.com