Uniform Civil Affidavit of Indigency

Supreme Court Pursuant to Tenn. Code Ann. § 20-12-127(a), any civil action may be commenced by a resident of this state without giving security as required by law for costs and without payment of litigation taxes due by filing the oath of poverty set out in the statute and by filing an affidavit of indigency as prescribed by court rule. Pursuant to Tenn. Code Ann. § 20-12-127(a)(2), the uniform civil affidavit of indigency document appended to this rule is hereby adopted and shall be used in all such civil cases. The uniform civil affidavit of indigency shall also be used in all cases commenced pursuant to Tenn. Code Ann. § 20-12-128 (pertaining to the pauper’s oath in actions filed by guardians), § 20-12-129 (actions filed by next friends of infants) and § 20-12-130 (actions filed by personal representatives). In deciding whether a civil action commenced under a pauper’s oath should be dismissed pursuant to § 20-12-132, the court shall consider the information required by the uniform civil affidavit of indigency. A person who meets the Legal Services Corporation’s poverty guidelines published annually in the Code of Federal Regulations shall be presumed to be indigent for purposes of Tenn. Code Ann. § 20-12-127, § 20-12-128, § 20-12-129, and § 20-12-130. The foregoing sentence does not preclude the court from finding that a person who does not meet the Legal Services Corporation’s poverty guidelines is indigent for purposes of the pauper’s oath statutes. This rule shall not be interpreted to modify or repeal any provision contained in Tenn. Code Ann. §§ 41-21-801 through -818, which apply to claims filed by inmates. [Effective June 21, 2001.] IN THE ______ COURT OF ______ COUNTY ___________ ) (PLAINTIFF) ) ) VS. ) CASE NO: _______ ) ___________ ) (DEFENDANT) ) _____________________ UNIFORM CIVIL AFFIDAVIT OF INDIGENCY _____________________ I, _______, having been duly sworn according to law, make oath that because of my poverty, I am unable to bear the expenses of this case 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: _____________________ 2. Address: _____________________ 3. Telephone Number: _____________________ 4. Date of Birth: _____________________ 5. Names and Ages of All Dependents: ________________ Relationship _____________________ ________________ Relationship _____________________ ________________ Relationship _____________________ ________________ Relationship _____________________ 6. I am employed by: _____________________ My employer's address is: _____________________ My employer's phone number is: _____________________ 7. My present income, after federal income and social security taxes are deducted, is: $_____ 8. I 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 ______ Worker's Compensation $______ per month beginning ______ Other $______ per month beginning ______ 9. My expenses are: Rent/House Payment $_________ per month Groceries $_________ per month Electricity $_________ per month Water $_________ per month Gas $_________ per month Transportation $_________ per month Medical & Dental $_________ per month Telephone $_________ per month School Supplies $_________ per month Clothing $_________ per month Child Care or Court Ordered Child Support $_________ per month Other $_________ per month 10. Assets: Automobile $_________ (Fair Market Value) Checking/Savings Account $_________ House $_________ (Fair Market Value) Other $_________ 11. 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. _____________________ PLAINTIFF ORDER ALLOWING FILING ON PAUPER'S OATH It appears based upon the Affidavit of Indigency filed in this cause and after due inquiry made that the Plaintiff is an indigent person and is qualified to file case on a pauper's oath. It is so ordered this the _____ day of _______, 20___. _____________________ JUDGE DETERMINATION OF NONINDIGENCY It appearing based upon the Affidavit of Indigency filed in this cause and after due inquiry made that the Plaintiff is not an indigent person because _____________________ IT IS ORDERED AND ADJUDGED that the Plaintiff does not qualify for filing this case on a pauper's oath. This the ____ day of _______, 20___. _____________________ JUDGE _____________________ NOTICE: If the judge determines that based upon your affidavit you are not eligible to proceed under a pauper's oath, you have the right to a hearing before the judge or, in those cases that can be appealed to Circuit Court, a hearing before the Circuit Court judge. _____________________ [Amended by order filed April 6, 2001.] Rule Name Rule 29: Uniform Civil Affidavit of Indigency.