"Uniform Civil Affidavit of Indigency" - Tennessee

Uniform Civil Affidavit of Indigency is a legal document that was released by the Tennessee State Courts - a government authority operating within Tennessee.

Form Details:

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  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Tennessee State Courts.

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Download "Uniform Civil Affidavit of Indigency" - Tennessee

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_____________ Court
U
C
NIFORM
IVIL
____________ County
Case Number
____________ Tennessee
A
I
FFIDAVIT OF
NDIGENCY
page 1 of 2
_____________________________________________ 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 employer’s address is: ________________________________________________________________________________
My employer’s 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 _________
Worker’s 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 PAUPER’S 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 pauper’s oath.
_____________ Court
U
C
NIFORM
IVIL
____________ County
Case Number
____________ Tennessee
A
I
FFIDAVIT OF
NDIGENCY
page 1 of 2
_____________________________________________ 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 employer’s address is: ________________________________________________________________________________
My employer’s 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 _________
Worker’s 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 PAUPER’S 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 pauper’s oath.
_____________ Court
U
C
NIFORM
IVIL
____________ County
Case Number
____________ Tennessee
A
I
FFIDAVIT OF
NDIGENCY
page 2 of 2
_____________________________________________ 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 pauper’s 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 pauper’s 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.
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