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
$
$
Other
$
Water
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.
$
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.
•
I cannot afford to pay the filing fees at this time.
Perjury means lying on purpose. If I lie on purpose I may have to pay a fine or go to jail.
Sign here:
Date:
Sworn and subscribed before me this _________ day of ______________________, 20_________.
________________________________________
_____________________________________
Notary Public or Deputy Clerk
My Term Expires
IMPORTANT!
Take any proof that supports your case to the hearing, including: witnesses, photos, papers,
receipts, etc. The court will not accept written statements from witnesses. The person must go to
court in person. If you think a witness may not want to go to court, ask the clerk for subpoena forms.
Complete the subpoena as soon as possible so the sheriff can serve them before court.
Request to Postpone Filing Fees and Order
Page 3 of 4
July 2017