Page 5 - Knox County_Community Service Program Guide
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KNOX COUNTY CRIMINAL COURT

                              COMMUNITY SERVICE PROGRAM AFFIDAVIT OF INDIGENCE
                                                      KNOXVILLE, TENNESSEE

                  STATE OF TENNESSEE                                 CASE/DOCKET NO.
                  vs.


                  DEFENDENT


                  Comes the defendant and, subject to the penalty of perjury, makes oath of the following facts
                  (Please list, circle, complete, etc.)

                  1.  Full Name:
                  2.  List any other names ever used:
                  3.  Birthdate:  _______________________  Gender:          Male          Female
                  4.  Address:
                  5.  Telephone No(s):  (Home)                        (Work)                (Mobile)
                  6.  Are you currently employed?     Yes    No   If yes, Where?
                  7.  How much money do you make?  $                   Per hour/day/week/month/year (circle one)
                  8.  Do you have any income other than the income listed above?      Yes    No
                        If yes, list the total amount:  $                                 (weekly, monthly, etc.)
                        List Source of Income(s):
                      Remember, possible sources include, but are not limited to the following:  interest, gifts,
                      AFCD, SSI, social security, retirement, disability, pension, unemployment, alimony, and
                      workers’ compensation.
                  9.   Do you hold a HMIS (Homeless Management Information System) Card?         Yes     No
                 10.   What is your total income after taxes $
                 11.   Your last income tax return filed was in the year
                         Can you provide your last filed federal income tax return?         Yes   No
                         Your last return reflected an adjust gross income of $
                 12.   If you are unable to provide you last federal income return filed, can you provide the last
                      paystub you received?       Yes    No
                 13.  Do you own property?        Yes    No
                      List all vehicles/vessels/real estate owned by me, solely or jointly, including, but not
                      limited to: cars, trucks, motorcycles, farm equipment, boats, land, lots, houses, mobile
                      homes, etc.
                      Description:                    Value $               Owned      Amt. Owed:
                      Description:                    Value $               Owned      Amt. Owed:
                      Description:                    Value $               Owned      Amt. Owed:
                      Description:                    Value $               Owned      Amt. Owed:
                      Description:                    Value $               Owned      Amt. Owed:
                      Description:                    Value $               Owned      Amt. Owed:
                        Other property valued over $1,000:
                 13.  All money available to me from any source:
                         Cash:
                         Checking, Saving, or CD Account(s) Balance:
                         Debts owed to me:


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