Page 6 - Knox County_Community Service Program Guide
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Credit Card(s) (Visa/MasterCard/American Express/Other):
                         Account Number:                      Balance:             Credit Limit:
                         Account Number:                      Balance:             Credit Limit:
                         Account Number:                      Balance:             Credit Limit:
                         Account Number:                      Balance:             Credit Limit:
                         Account Number:                      Balance:             Credit Limit:

                 14.  Number of persons in your family/household:
                 15.  Name and ages of all dependents:
                        Name:                         Age:           Relationship:
                        Name:                         Age:           Relationship:
                        Name:                         Age:           Relationship:
                        Name:                         Age:           Relationship:
                        Name:                         Age:           Relationship:

                 16.  My expenses are:
                      Rent/House Payment $_________ per month                     Groceries   $_________ per month
                      Electricity   $_________ per month                   School Supplies   $_________ per month
                      Water    $_________ per month                                                Clothing   $_________ per month
                      Gas   $_________ per month                                     Medical & Dental   $_________ per month
                      Transportation   $_________ per month                           Telephone     $_________ per month
                         Court Ordered Child Support:                           Child Care $_________ per month
                         $_________ per month                                                            Other    $_________ per month

                 17.   Which legal representation listed below was used for your most recent offense?
                                  Pro se (Represented Self)      Court Appointed Attorney          Paid for Attorney
                 18.   Do you have any construction, carpentry or specific trade skills?      Yes       No
                               If yes, please describe: _____________________________________________________
                 19.   Are you physically able to lift a minimum of 25 lbs.?          Yes      No

                  Acknowledging that I am still under oath, I certify I completed the above Affidavit truthfully,
                  listing all assets in which I hold or expect to hold any legal or equitable interest.

                  I am financially unable to pay all fines and court costs.

                  I understand that it is a Class A Misdemeanor for which I can be sentenced to jail for up to 11
                  months and 29 days or be fined up to $2500.00 or both if I intentionally or knowingly
                  misrepresent, falsify, or withhold any information required in the affidavit. I also understand
                  that I may be required by the Court to produce other information in support of my request to
                  participate in the Knox County Court Community Service Program.

                  This           day of                     , 20     .
                                                                                   APPLICANT

                  Sworn to and subscribed before me.   This          day of                    , 20          .

                  Notary Public: __________________________________

                  My Commission Expires: __________________________

                                                                                                                          Reserved for Notary Seal
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