December 2012 Request Not to Pay Fees for Appeal Page 1 of 2
Approved by the Tennessee Supreme Court
If you do not have enough money to pay for the court costs to start your appeal, you may fill out this form.
You may have to pay court costs at the end of the case.
I, _____________________________________________________________________, do solemnly swear
that I am a resident of the State of Tennessee, and that owing to my poverty, I am not able to bear the
expense of an appeal from the judgment of the Court in the above styled case and that I am justly entitled to
the relief sought to the best of my belief.
Read below t
hen sign:
I declare under penalty of perjury under the laws of the State of Tennessee that:
• I swear
that I do not have enough money or assets to pay the court costs for my appeal before the
court date.
• I ask the court to allow me to appeal without paying the fees at this time.
• The information on this form is true to the best of my knowledge.
Party Appealing : Date:
Sworn and subscribed before me, this __________ day of _______________________, 20____.
Deputy Clerk: __________________________________________________________________
Notice: Loss of appeal results in obligation to pay court costs.
____________________________________________ _______________________________________
Lawyer for Plaintiff Lawyer for Defendant
____________________________________________ ________________________________________
Lawyer’s Address Lawyer’s Address
____________________________________________ ________________________________________
City, State, Zip City, State, Zip
____________________________________________ ________________________________________
Plaintiff(s) Defendant(s)
____________________________________________ ________________________________________
Home Address and Telephone Home Address and Telephone
____________________________________________ ________________________________________
City, State, Zip City, State, Zip
____________________________________________ ________________________________________
Place of Employment and Telephone Place of Employment and Telephone
State of Tennessee
(Must Be Completed)
(Must Be Completed)
Pay Fees for Appeal
(Pauper’s Oath in Lieu of Appeal Bond)
File No. __________________
(Must Be Completed)
Division __________________
(Large Counties Only)
Plaintiff ______________________________________________________________________________
(Name: First, Middle, Last of person/company that filed lawsuit)
Defendant ____________________________________________________________________________
(Name: First, Middle, Last of the other person)
