Uniform Affidavit Of Indigency Form - Tennessee (Page 2 of 2) in pdf

___________Court

NIFORM

FFIDAVIT OF

Case Number

__________ County

__________ Tennessee

NDIGENCY

page 2 of 2

_____________________________________ vs. _____________________________________

_________________________________________________________________________________________________

E. Other ___________________________________________________________________________________________

18. All vehicles/vessels owned by me, solely or jointly, within the last six months (including but not limited to cars, trucks,

motorcycles, farm equip., boats etc.):

________________________ value $ __________________ amt. owed ________________

19. All real estate owned by me, solely or jointly, within the last six months (including land, lots, houses, mobile homes, etc.):

________________________ value $ __________________ amt. owed ________________

20. All assets or property not already listed owned within the last six months or expected in the future:

_____________________________ value $ __________________ amt. owed _________________

21. The last income tax return I filed was for the year ______ and it reflected a net income of $ ___________________________.

I will file a copy of same within one week if required.

22. I am out of jail on bond of $ ___________ made by ___________________________. The money to make bond, $ ________ was

paid by __________________________________________________.

PART III

23. Acknowledging that I am still under oath, I certify that I have listed in Parts I and II all assets in which I hold or expect to hold any

legal or equitable interest.

24. I am financially unable to obtain the assistance of a lawyer and request the court to appoint a lawyer for me.

25. I understand that it is a Class A misdemeanor for which I can be sentenced to jail for up to 11 months 29 days or be fined up to

$2500.00 or both if I intentionally or knowingly misrepresent, falsify, or withhold any information required in this affidavit. I also

understand that I may be required by the Court to produce other information in support of my request for an attorney.

This __________ day of ______________, ________.

__________________________________________

Defendant

Sworn to and Subscribed before me this ____ day of __________, ________.

__________________________________________

Clerk

__________________________________________

Judge

Legal Authority: Tenn. Rule Sup. Ct. 13

Uniform Affidavit Of Indigency Form - Tennessee Page 2