Uniform Affidavit Of Indigency Form - Tennessee
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1
2___________Court
U
A
NIFORM
FFIDAVIT OF
Case Number
__________ County
I
__________ Tennessee
NDIGENCY
page 1 of 2
_____________________________________ vs. _____________________________________
Comes the defendant and, subject to the penalty of perjury, makes oath to the following facts (please list, circle, complete, etc.):
PART I
1. Full Name: _________________________________
2. Social Security No.: _________________
3. Any other names ever used: ____________________
4. Address: _________________________
5. Telephone Nos.: (Home) __________________ (Work) _________________ (Other) __________________
6. Are you working anywhere? Yes ( ) No ( ) Where ______________________________________________
7. How much do you make? __________ (weekly, monthly, etc.)
8. Birth date: _________________________
9. Do you receive any governmental assistance or pensions (disability, SSI, AFDC, etc.)? Yes ( ) No ( )
What is its value? ________________________ (weekly, monthly, etc.)
10. Do you own any property (house, car, bank acct., etc.): Yes ( ) No ( )
What is its value? ______________________________________________________
11. Are you, or your family, going to be able to post your bond? Yes ( ) No ( )
12. Are you, or your family, going to hire a private attorney? Yes ( ) No ( )
13. Are you now in custody? Yes ( ) No ( )
If so, how long have you been in custody? ____________________________________________________
(If the defendant is in custody, unable to make bond and the answers to questions one (1) through eleven (11) make it clear that the defendant has
no resources to hire a private attorney, skip Part II and complete Part III. If Part II is to be completed, do not list items already listed in Part I.)
PART II
14. Names & ages of all dependents: ________________________
relationship ____________________
___________________________________________________
relationship ____________________
___________________________________________________
relationship ____________________
15. I have met with following lawyer(s), have attempted to hire said lawyer(s) to represent me, and have been unable to do so:
Name ____________________________________
___________________________________
Address ___________________________________
___________________________________
16. All my income from all sources (including, but not limited to wages, interest, gifts, AFDC, SSI, social security, retirement,
disability, pension, unemployment, alimony, worker's compensation, etc.):
$ ______________ per ________________________ from ____________________________________________________
$ ______________ per ________________________ from ____________________________________________________
$ ______________ per ________________________ from ____________________________________________________
17. All money available to me from any source:
A. Cash __________________
B. Checking, Saving, or CD Account(s)-give bank, acct. no., balance __________________________________________
C. Debts owed me __________________________________________________________________________________
D. Credit Card(s)-give acct. no., balance, credit limit, and type (Visa, Mastercard, American Express, etc.) ____________
Legal Authority: Tenn. Rule Sup. Ct. 13
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