AFFIDAVIT OF INDIGENCY I, , do solemnly swear or affirm under penalties of perjury, that owing to poverty, I am not able to bear the expense of the furnishing of my medical record(s), and that any future action will be filed with the Court, along with a Pauper's Oath, pursuant to Tennessee Code Annotated, § 20-12-127. I am, am not, represented by an attorney and this is my first request for any or all of my medical record(s). Signature of Patient Date: Birth Date: Social Security Number: State of Tennessee County of Subscribed and sworn to before me, this day of , 20 . By: Notary Public
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