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 to the __________________________ Court of ________________________________County, at ____________________________Tennessee, which has this day been taken and granted, and that I am justly entitled to the relief sought, to the best of my belief.

Sworn to and subscribed before me, this day________ day of _______________, 2______.

	    													
     						       	Clerk / Deputy Clerk