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

PART I
1. Full Name: _________________________________   	2. Other names used: ___________________

3. Birth date:__________________________________   	4.  Address: __________________________ 

5. Telephone Nos.: (Home) __________________ (Work) _________________ (Other) __________________ 

6. Are you working anywhere? Yes (  ) No (  ) Where ______________________________________________ 

7. How much do you make? __________ (weekly, monthly, etc.) 	

8. Do you receive any governmental assistance or pensions (disability, SSI, AFDC, etc.)?  Yes ( ) No ( ) 
	What is its value? ________________________ (weekly, monthly, etc.)

9. Do you own any property (house, car, bank acct., etc.): Yes ( ) No ( ) 
	What is its value? ______________________________________________________ 

10. Total annual income after taxes is: $_________________  			 

PART II
11. Number of members in your household: __________________

12. Names & ages of all dependents: ________________________ 	relationship ____________________
	__________________________________________________ 	relationship ____________________ 
      ___________________________________________________	relationship ____________________

13. All my income from all sources (including, but not limited to wages, interest, gifts, AFDC, SSI, social security, retirement, disability, pension, unemployment, alimony, worker's compensation, etc.):

  $ ______________ per ________________________ from ____________________________________________________ 

  $ ______________ per ________________________ from ____________________________________________________ 

  $ ______________ per ________________________ from ____________________________________________________ 

14. All money available to me from any source:  
	A. Cash __________________ 
	B. Checking, Saving, or CD Account(s)-give bank, acct. no., balance __________________________________________ 
	C. Debts owed me __________________________________________________________________________________
	D. Other ___________________________________________________________________________________________

15. I owe the following debts:

  $ ______________ to:  ________________________
  $ ______________ to:  ________________________
  $ ______________ to:  ________________________

16. All vehicles/vessels owned by me, solely or jointly, within the last six months (including but not limited to cars, trucks, motorcycles, farm equip., boats etc.):

             ________________________ value $ __________________ amt. owed ________________ 

             ________________________ value $ __________________ amt. owed ________________ 

             ________________________ value $ __________________ amt. owed ________________ 

17. All real estate owned by me, solely or jointly, within the last six months (including land, lots, houses, mobile homes, etc.):

             ________________________ value $ __________________ amt. owed ________________ 

             ________________________ value $ __________________ amt. owed ________________ 

18. All assets or property not already listed owned within the last six months or expected in the future:

             _____________________________ value $ __________________ amt. owed _________________

             _____________________________ value $ __________________ amt. owed _________________ 

19. I am out of jail on bond of $ ___________ made by ___________________________.  The money to make bond, $ ________ was paid by __________________________________________________. 

20. Other circumstances that the court may find relevant to the issue of indigency: ________________________________________
                __________________________________________________________________________________________________
		  __________________________________________________________________________________________________
  
PART III
21. Acknowledging that I am still under oath, I certify that I have listed in Parts I and II all assets in which I hold or expect to hold any legal or equitable interest.

22. I agree to file a copy of my most recent income tax return if requested by the court.

23. I understand that, pursuant to the perjury offense set out in T.C.A. § 39-16-702, it is a Class A misdemeanor for which I can be sentenced to jail for up to 11 months, 29 days or be fined up to $2,500, or both, if I intentionally misrepresent, falsify or withhold any information required in this affidavit.  I also understand that I may be required by the Court to produce other information in support of my request to be declared indigent for purposes of using the electronic monitoring indigency fund.

This __________ day of ______________, ________. 	__________________________________________ 
	Defendant

 Sworn to and Subscribed before me this ____ day of __________, ________.

	__________________________________________
	Judge/Clerk
Judge must check one of the following: 

____  I hereby find that the above-named defendant is NOT indigent and does not qualify for financial assistance to pay costs associated with a functioning ignition interlock device, transdermal monitoring device, other alternative alcohol or drug monitoring device, or global positioning monitoring device.

OR

____ I hereby find that the above-named defendant is indigent and, subject to availability of funds, qualifies for financial assistance to pay costs associated with a functioning ignition interlock device, transdermal monitoring device, other alternative alcohol or drug monitoring device, or global positioning monitoring system.

If defendant is declared indigent, the Judge must complete the next sections:

1. 	A.	____Defendant is ordered to pay a minimum of $30.00 per month toward the eligible costs for a functioning interlock device or alterative device, pursuant to T.C.A. § 55-10-419(h)(2). 

OR

B.	____Defendant is found to have the ability to pay more than the required $30.00 per month of the costs associated with the required device, and is ordered to pay $_____________, pursuant to T.C.A. §55-10-419(h)(2). 

AND

C.	____ Costs associated with the required device in the amount of $____________, [not to exceed $170/month, per device, pursuant to T.C.A. §55-10-419(h)(2)] may be reimbursed to the provider by the electronic monitoring indigency fund if eligible.  

The total cost of the required device is $____________.  [This is sum of Defendant’s portion (A or B) and EMIF portion (C), and must not to exceed $200.00/month]

2. Length of time the defendant is ordered to use/wear the device: ________

3. Number of devices the defendant is ordered to use/wear:_________

4. Type of device(s) ordered: 

____  Ignition interlock device			
____  Transdermal monitoring device
____  Other alternative alcohol or drug monitoring device (List type of device:__________________________________)
____  Global positioning monitoring system

____________________                     _______________________________________ 	
Date				      			Signature of Judge
NOTICE TO DEFENDANT: YOU MAY NOT BE CHARGED ANY AMOUNTS FOR ELECTRONIC MONITORING THAT ARE NOT AUTHORIZED BY THIS COURT ORDER.  T.C.A. §55-10-419(l).

****** A copy of this form must be submitted to the device provider of the ignition interlock device, transdermal monitoring device, other alternative alcohol or drug monitoring device, or global positioning monitoring devices. The device provider must submit a copy of this form to the County Government in which the issuing Court is located in form and fashion acceptable to said County prior to being reimbursed, along with a copy of the signed court order indicating that the use of the device(s) has been ordered by the Court. Pursuant to T.C.A. § 55-10-419(a)(1)(B), no more than two hundred dollars ($170.00) per month shall be expended from the fund to pay the costs associated with the device.	

United State Department of Health and Human Services
2023 Poverty Guidelines	
Persons in family/household	Poverty guideline	
1	$14,580	
2	$19,720	
3	$24,860	
4	$30,000	
5	$35,140	
6	$40,280	
7	$45,420	
8	$50,560	
For families/households with more than 8 persons, add $5,140 for each additional person.	

*Source: U.S. Department of Health & Human Services.  
Poverty Guidelines for the 48 Contiguous State and the District of Columbia, 2023