Uniform Civil Affidavit Of Indigency Rule 29

____________ Court Case Number: _____________ County UNIFORM CIVIL AFFIDAVIT OF INDIGENCY RULE 29 _______________ Tennessee Page 1 of 1 ___________________________________ 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 cause 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 : ____________________________________________ Date of Birth: _______________________________ 2. Address: _______________________________________________ Telephone Number: __________________________ 3. Dependents: Name: _______________________________ Age: _________ Relationship: ________________________ Name: _______________________________ Age: _________ Relationship: ________________________ Name: _______________________________ Age: _________ Relationship: ________________________ 4. I am employed by: ___________________________________________________ 5. My present income, after federal income and social security taxes, is $ _____________ per week of $ ___________ per month. 6. I am not employed, but 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 ______________________ Workers Compensation $________________ per month beginning ______________________ 7. My expenses are: Rent/House Payment $________________ per month Transportation $_________________ per month Groceries $________________ per month Medical $_________________ per month Electricity $________________ per month Telephone $_________________ per month Water $________________ per month Other $_________________ per month Gas $________________ per month 8. Assets Automobile $________________ Checking/Savings Acct. $________________ House $________________ Other $________________ 9. 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. Date: _________________________________ __________________________________________________ P laintiff ORDER ALLOWING FILING UPON OATH OF INDIGENCY It appears based upon the Uniform Civil Affidavit of Indigencyd filein this cause and after due inquiry made that the Plaintiff is an indigent person and is qualified to file case upon an oath of Indigency. Date: ____________________________ ____________________________________________Circuit Court Judge DETERMINATION OF NONINDIGENCY It appearing based upon the Uniform Civil Affidavit of Indigency file din this case and after due inquiry made that the Plaintiff is not an indigent person because ________________________________________________ _____________________________________. Date: ___________________________ ____________________________________________Circuit Court Judge NOTICE: If the judge determines that based upon your affidavit you are not eligible to proceed under a paupers path, you have the right to a hearing before the judge or, in certain cases, an appeal to C ircuit Court. Sworn to and subscribed before me this day __________________________________. My Commission Expires: _______________________ ____________________________________________Clerk/Notary Public