In the Chancery Court of Hamilton County, Tennessee

IN THE CHANCERY COURT OF HAMILTON COUNTY, TENNESSEE * ______, * Petitioner * CASE N0.______vs. * PART______, * Respondent *

AFFIDAVIT OF INMATE PURSUANT TO T.C.A. § 41-21-801, et seq.

1. Full Name:______2. Date of Birth:______3. Address:______4. Telephone Number: ______5. Tennessee Department of Correction Inmate N0.______6. Provide the following information for all lawsuits or claims ever filed regardless of whether or not you were incarcerated when the lawsuit or claim occurred. Lawsuits or claims you have filed under any other name must also be listed. All parts of Question 6 must be answered as to each lawsuit or claim you have previously filed. Attach additional sheets if necessary.

6.1 Case Name:______6.2 Case Number:______6.3 Name & Location of Court in which lawsuit or claim was filed:______6.4 The operative facts for which relief was sought in the lawsuit or claim:______6.5 The legal theory on which the relief sought was based:______6.6 Identification of each party named in the lawsuit or claim:______6.7 The final result of the lawsuit or claim:______6.8 Was the lawsuit or claim dismissed as either frivolous or malicious? YES NO 6.8.1 If YES, state the date of the final order affirming the dismissal:______7. A current, certified copy of your inmate trust account statement must be attached. Is it? YES NO 8. Was this claim subject to review by a grievance committee established by the Tennessee Department of Correction? YES NO 8.1 State the date the claim was filed with the grievance committee:______8.2 State the date you received a decision from a grievance committee:______8.3 A copy of the final decision from the grievance committee must be attached. Is it? YES NO

[Form 003, Rev. 2000.12.29] I hereby declare under penalty of perjury that the forgoing answers are true, correct and complete.

1 ______AFFIANT STATE OF TENNESSEE ) COUNTY OF ______)

Sworn to and subscribed to before me this ____ day of ______, 20___.

______My Commission Expires:______NOTARY PUBLIC OPTIONAL PAGE FOR ADDITIONAL INFORMATION

6. Provide the following information for all lawsuits or claims ever filed regardless of whether or not you were incarcerated when the lawsuit or claim occurred. Lawsuits or claims you have filed under any other name must also be listed. All parts of Question 6 must be answered as to each lawsuit or claim you have previously filed. Attach additional sheets if necessary.

6.1 Case Name:______6.2 Case Number:______6.3 Name & Location of Court in which lawsuit or claim was filed:______6.4 The operative facts for which relief was sought in the lawsuit or claim:______6.5 The legal theory on which the relief sought was based:______6.6 Identification of each party named in the lawsuit or claim:______6.7 The final result of the lawsuit or claim:______6.8 Was the lawsuit or claim dismissed as either frivolous or malicious? YES NO 6.8.1 If YES, state the date of the final order affirming the dismissal:______7. A current copy of your inmate trust account statement must be attached. Is it? YES NO 8. Was this claim subject to review by a grievance committee established by the Tennessee Department of Correction? YES NO 8.1 State the date the claim was filed with the grievance committee:______8.2 State the date you received a decision from a grievance committee:______8.3 A copy of the final decision from the grievance committee must be attached. Is it? YES NO

[Form 003, Rev. 2000.12.29]