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.]