Request To Make Payments Form - Tennessee Page 3

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List all bank/financial accounts below:
Bank name
Balance
5.
$
6.
$
7. Cash
$
Total:
$
Other:
Expenses
How much each
How much each
month?
month?
Rent/House Payment $
Gas
$
Phone
$
Child Care
$
Court-ordered Child
Groceries
$
$
Support
School Supplies
$
Transportation
$
Electricity
$
Medical/Dental
$
Clothing
$
Other
$
Water
$
Other
$
Debts:
How much do you
How much do you
Who do you owe?
owe?
Who do you owe?
owe?
1.
$
4.
$
2.
$
5.
$
3.
$
6.
$
List any other facts you want the court to know, such as unusual medical expenses, family
emergencies, etc.
I declare under penalty of perjury under the laws of the State of Tennessee that:
•
The information I have provided is true, correct, and complete.
Sign here:
Date:
Sworn and subscribed before me this _______ day of _____________________, 20________.
Bring the original and 2 copies of this form to the Court Clerk to be date stamped.
______________________________________
Give the original to the Court Clerk.
Deputy Clerk or Notary Public
Bring a stamped envelope addressed for each plaintiff to the Court Clerk. Mail one copy to the lawyer
or if there is no lawyer, mail it to the plaintiff or company that sued you. Keep one copy for yourself.
December 2012
Request to Make Payments
Page 3 of 4
Approved by the Tennessee Supreme Court

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