Rev. 07/18 Authority: T.C.A. 247 55-10-419(e) IN THE COURT FOR COUNTY STATE OF TENNESSEE vs. Case/Docket No. or Warrant No. Defendant DOB: UNIFORM AFFIDAVIT OF INDIGENCY FOR PURPOSES OF ELECTRONIC MONITORING INDIGENCY FUND (T.C.A. 247 55-10-419) Comes the defendant and, subject to the penalty of perjury, makes oath to the following facts (please list, circle, complete, etc.): 1. Full name: List any other names you have used: 2. Address: 3. Telephone Nos.: (Home/Cell) (Work) 4. Are you working? ( ) Yes ( ) No If yes, where? 5. How much money do you make? $ per hour/day/week/month/year (circle one) 6. Do you have any income other than the income listed above? ( ) Yes ( ) No If yes, list the total amount. $ Remember, possible sources include, but are not limited to the following: interest, gifts, AFDC, SSI, social security, retirement, disability, pension, unemployment, alimony, and workers222 compensation. 7. Your total annual income after taxes is $ 8. Number of persons in your family/household: 9. Acknowledging that I am still under oath, I certify that I have listed above all income I receive. 10. By signing this form, I agree to file a copy of my most recent income tax return if requested by the court. 11. I understand that, pursuant to the perjury offense set out in T.C.A. 247 39-16-702, it is a Class A misdemeanor for which I can be sentenced to jail for up to 11 months, 29 days or be fined up to $2,500, or both, if I intentionally misrepresent, falsify or withhold any information required in this affidavit. I also understand that I may be required by the Court to produce other information in support of my request to be declared indigent for purposes of using the electronic monitoring indigency fund. This day of , . . Signature of Defendant Sworn to and Subscribed before me this day of , . Signature of Judge/Clerk American LegalNet, Inc. www.FormsWorkFlow.com Rev. 07/18 Authority: T.C.A. 247 55-10-419 Order Regarding Indigency Determination for Purposes of Payment by the Electronic Monitoring Indigency Fund I hereby find that the above-named defendant is NOT indigent and does not qualify for financial assistance to pay costs associated with a functioning ignition interlock device, transdermal monitoring device, or alternative alcohol or drug monitoring device. OR I hereby find that the above-named defendant receives an annual income, after taxes, of 185% or less of the poverty guidelines updated periodically in the federal register by the United States Department of Health and Human Services under the authority of 42 U.S.C. 247 9902(2), and that the defendant is therefore indigent and, subject to availability of funds, qualifies for financial assistance to pay costs associated with a functioning ignition interlock device, transdermal monitoring device, or alternative alcohol or drug monitoring device. If defendant is declared indigent, complete the next sections: 1. Defendant is found to have the ability to pay a portion of the costs associated with the required device, and is ordered to pay $, pursuant to T.C.A. 24755-10-419(b). Costs associated with the required device in the amount of $, (not to exceed $200/month, per device) will be reimbursed to the provider by the electronic monitoring indigency fund. The total cost of the required device is $. 2. Length of time the defendant is ordered to use/wear the device: 3. Number of devices the defendant is ordered to use/wear: 4. Type of device(s) ordered: Ignition interlock device Transdermal monitoring device Other alternative alcohol or drug monitoring device (List type of device: ) Date Signature of Judge ****** The defendant must submit a copy of this form to the device provider before installation of the ignition interlock device, transdermal monitoring device, or alternative alcohol or drug monitoring device; and the device provider must submit a copy of this form to the state treasurer prior to being reimbursed, along with a copy of the signed court order indicating that the use of the device(s) has been ordered by the Court. Pursuant to T.C.A. 247 55-10-419(a)(1)(C), no more than two hundred dollars ($200.00) per month shall be expended from the fund to pay the costs associated with the device. American LegalNet, Inc. www.FormsWorkFlow.com Source: U.S. Department of Health & Human Services Poverty Guidelines for the 48 Contiguous States and the District of Columbia Rev. 1/13/18 United States Department of Health and Human Services 2018 Poverty Guidelines Persons in Family/Household Poverty Guideline 185% 1 $12,140 $22,459 2 $16,460 $30,451 3 $20,780 $38,443 4 $25,100 $46,435 5 $29,420 $54,427 6 $33,740 $62,419 7 $38,060 $70,411 8 $42,380 $78,403 For families/households with more than 8 persons, add $4,320 for each additional person. American LegalNet, Inc. www.FormsWorkFlow.com