Uniform Civil Affidavit Of Indigency (Print Double Sided Onto One Sheet)

IN THE CHANCERY COURT FOR DAVIDSON COUNTY, TENNESSEE TWENTIETH JUDICIAL DISTRICT _________________________________________ (PLAINTIFF) VS. _________________________________________ (DEFENDANT) ) ) ) ) ) ) CASE NO. ____________________ UNIFORM CIVIL AFFIDAVIT OF INDIGENCY I, _____________________________________________, having been duly sworn according to law, make oath that because of my poverty, I am unable to bear the expenses of this cause and that I am justly entitled to the relief sought to the best of my belief. The following facts support my poverty. 1. 2. 3. 5. Full Name: Address: _____________________________________________________________________________ _____________________________________________________________________________ Telephone Number: _______________________________ 4. Date of Birth: ______________________________ Names and Ages of All Dependents: _______________________________________ Relationship ________________________ _______________________________________ Relationship ________________________ _______________________________________ Relationship ________________________ _______________________________________ Relationship ________________________ 6. I am employed by: ___________________________________________________________ My employer's address is: _____________________________________________________ My employer's telephone number is: _____________________________________________ 7. My present income, after federal income and social security taxes are deducted, is: $_________________ per week or $__________________ per month. 8. I receive or expect to receive money from the following sources: AFDC SSI Retirement Disability Unemployment Worker's Compensation Other $__________ per month beginning ________________ $__________ per month beginning ________________ $__________ per month beginning ________________ $__________ per month beginning ________________ $__________ per month beginning ________________ $__________ per month beginning ________________ $__________ per month beginning ________________ American LegalNet, Inc. www.FormsWorkFlow.com 9. My expenses are: Rent/House Payment Groceries Electricity Water Gas Transportation Medical/Dental Telephone School Supplies Clothing Child Care or Court-Ordered Child Support Other $ _______________________________ per month $ _______________________________ per month $ _______________________________ per month $ _______________________________ per month $ _______________________________ per month $ _______________________________ per month $ _______________________________ per month $ _______________________________ per month $ _______________________________ per month $ _______________________________ per month $ _______________________________ per month $ _______________________________ per month 10. Assets: Automobile Checking/Savings Account House Other $ _______________________________ $ _______________________________ $ _______________________________ $ _______________________________ (Fair Market Value) (Fair Market Value) 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 (Rev. 8/07) American LegalNet, Inc. www.FormsWorkFlow.com