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In forma Pauperis Affidavit

In the case of wanting to proceed in forma pauperis by people who are eligible to do so, the following form has to be completed and submitted.

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_____________________________    *  _______ JUDICIAL DISTRICT COURT 
 
VERSUS     * DOCKET NUMBER: __________Div.___ 
 
_______________________________       *          _______________ PARISH, LOUISIANA 
 
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * \
* * * * * * * * * * * * * * * *  	
In Forma Pauperis Affidavit	 	
 
All questions must be answered in full.	
 
 
Note	
:  Questions 2 and 3 should not be filled in if you are seeking protecti\
on from abuse.        	
 
1.   Your Full Name: ___________________________________________________\
_______ 
 
     Social Security Number	
 (Optional): 	_________________   Date of Birth:  _______________ 
 
     Age: ____________                      Sex	
 : _________ 
 
2. Address:   _________________________________________________________________ 
                         (Box Number or Street Address)                     (City and State)                          (Zip Code ) 
                       (See Note above)  
 
3.  Telephone Number(s):  	
(HOME	) ________________   	(WORK	) _____________________ 	
                                                 	(See Note above) 
 
4.  Are you a Student?  ____YES     ___NO    If yes, please indicate the name of the school you 
are attending: _________________________________ 	
   Enrollment Status:  ____________ 
 
5.  Current Household:  Single:___   Married:___  Separated:___  Di vorced:___  W	
 idowed:___  Intimate partner:___ 
      How many children do you support who are under 18?  _________________________ 	
 
      	
How many children live with you?  ________	   Do you have any other dependents?_______ 
      State the Name, Age and Relationship to you of the children and dependents: 	
       NAME                                                                    \
                                AGE        RELATIONSHIP   	
   
   
   
   
   	
 
6. What is your current Occupation? ________________Are you employed?	
 __YES  ___NO	 	
     (	If yes, please complete the following Employer Information)	 	
     Name of Employer: ___________________________________________________________ 
     	Address: _______________________________________________________________\
____ 	
     (Street Address)         (City and State)           (Zip Code)  
     Telephone Number:  ______________________   How long have you been employed? ____ 
      
     (If you are not employed, please provide information of your  last employer
 ) 
     Name of last employer:  _____________________________________________________ 
     Address: __________________________________________________________\
_________  
     (Street Address)     (City and State)         (Zip Code)	  
     How long have you been unemployed? _________________________________ 
     What were your monthly wages?  ___________________ 
 
7.  Gross Income:  (a) State your gross earned income from wages and how you are paid:   W	
 eekly? ____ Bi-Weekly? ____ Monthly? ____          Amount/month $__________  
       
 	
(b) Apart from income or support listed in response to question 8(b) below, how much other 
income do you receive on a monthly basis?                                                           $__________	
 
  
 (c)  	
Monthly Deductions: Federal Income Tax: $_______  FICA: $_______        $ _________ 
 
  (d) Other deductions: (explain) ____________________________________\
__ 	
      	 
      TOTAL NET MONTHLY INCOME: (Add question 7 (a) + (b) less (c))   \
    $ _________	
 	
  	
Revised October 2003                                                                          \
                                                                                                           Page 1  of  4

8(a).   If you are married and live with a spouse, please answer:  
Is your spouse employed?_______  What is the occupation of your spouse?_______________ 
Is your spouse paid Weekly? ___ Bi-Weekly? ___ Monthly? ___  Amount/month $_________ 
Name of spouse’s employer:_____________________________________________________ 
Address:  ______________________________________________________________\
______ 
     ( Street Address)   (City and State)    (Zip Code)  
Telephone Number: __________________  How long has spouse been employed? ________ 
 
8(b).  Do you or your spouse receive any of the following income or support? __ YES __ NO
  
If yes, state the monthly amount .   SSI: $____________  Disability: $_____________     
W	
 orker’s Comp: $____________     Unemployment Benefits: $________   
Food Stamps: $_____________ TANF: $_____________   Child Support: $____________	
    	
Spousal Support: $ _________	 Kinship Care Subsidy Grant:	 $__________     Other: $________ 
 
If you are a client of a legal services program  funded by the Legal Service Corporation or a 
Pro Bono Project that receives referrals from a legal services program  	

and have a 
combined income from questions 7 and 8 that is less than or equal to 125\
% of the federal 
poverty level, skip all parts of question 9, a nd continue with question 10 on the next page. 
 
9.  Do you own or have an interest in any of the following? 	(Including community property	) 
A.                      	
VALUE  OF INTEREST            BALANCE OWED 
HOUSE  $ $ 	
AUTOMOBILE $ $ 
TRUCK $ $ 
WATERCRAFT $ $ 
LIVESTOCK $ $ 
MACHINERY $ $ 
STOCK $ 	 	
BONDS $ 	 	
CERTIFICATES OF DEPOSIT $ 	 	
OTHER IMMOVABLE PROPERTY 	Equity 	$ 	Debt	 $ 	
DO YOU HAVE A BANK ACCOUNT(S)? __YES  __ NO    Amount in account(s): $________ 
___CHECKING   ____SAVINGS    	
Name and Location of Bank:  ____________________________ 	
TOTAL VALUE OF ASSETS :  $ ___________	 
 
B. i.  List your Monthly Expenses: 	
Rent: $  Cable: $  Car Note: $ 
Lot Rent: $ Garbage: $  Car Insurance: $ 
House Note: $ Medical Insurance: $  Transportation: $ 
House Insurance: $ Medical Expenses: $  Food: $ 
Gas: $ Dental Expenses: $  Barber/ Beauty: $ 
Electricity: $ Prescriptions: $  Entertainment: $ 
Water: $ Life Insurance: $  Grooming Supplies: $ 
Telephone: $ Daycare: $  Garnishment: $ 
Property Taxes: $ Child Support: $  Other: $ 
Total Amount of section i:       $___________ 
 
ii.  Credit cards: 	
(List type of card and monthly payment) 
Card Name                                      Monthly Payment 
 $ 	
 $ 
 $ 
 $ 
Total Amount of section ii:       $___________ 
 
iii.  Financial Loans: 	(List the financial institution and your monthly payment) 	
 Financial Name                        Monthly Payment	  
  	
  
  
  
Total Amount of section iii:       $___________ 
 
TOTAL MONTHLY EXPENSES:	 ( Add 9B (i+ii+iii) =Total Monthly Expenses )  	$___________	 
 
 
 
 
Revised October 2003                                                    \
                                                                                                                            \
      Page 2  o	
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10.  Does anyone regularly help you pay your expenses?                            _____YES ____NO 
(a)   	If yes, state that person’s name and relationship to you. 	
       	Name: ________________________________             Relationship: ___________________ 
(b). 
Do you have any additional income or assets that are  not shown above?              _____YES  ____NO 
       If you answered yes to either (a) or (b), please explain: 	
    ______________________________________________________________________\
____ 
 
     _____________________________________________________________________\
____ 
 
    ______________________________________________________________________\
____ 
 
11.  If you have an attorney, what arrangements have you made to pay your attorney’s fee?  
       What amount, if any, have you paid? 	
(You are required to answer fully.)               
       	
__________________________________________________________________________ 
________________________________________________________________________\
__ 
 	
12.  Has your attorney or the Notary Public told you that you may go to \
jail if you  
       intentionally give a false answer to any of the above questions?   ____YES  _____NO 
 
 	
MOVER’S AFFIDAVIT	 	
 
STATE OF LOUISIANA 
PARISH OF	
 _________________________________  	
   BEFORE ME the undersigned authority personally came and appeared: 
___________________________________ 
    who, after being duly sworn, deposed and said: 
   1.   He/She provided the information above; that the information is furnished to the court for  the purpose of requesting perm	
 ission to litigate the above captioned lawsuit without 
paying the costs in advance or as they accrue or furnishing security the\
refor. 
      
  2.   That the above information is a true and correct statement of his/her financial condition.   
3.   That the pleading and all allegations of fact therein are true and \
 correct; and that 
 
 because of his/her poverty and want of means, he/she is unable to pay the costs of court 
  in advance or as they accrue, nor is he/she able to provide security the\
refor. 
 
  4.   He/She has read and understands the privilege contained in the noti\
ce below. 
 	
NOTICE	 	
  Although you may be granted the privilege of proceeding without prepayment of costs, 
SHOULD JUDGMENT BE RENDERED AGAINST YOU , 
 YOUR STATUS AS A 
PAUPER DOES NOT RELIEVE YOU OF THE OBLIGATION TO PAY THESE COSTS	. 
 
  The privilege to proceed  IN FORMA PAUPERIS	
  is restricted to litigants who are clearly 
entitled to do so, with due regard to the nature of the proceeding, the \
court costs which otherwise 
would have to be paid, and the ability of the litigant to pay them or to furnish security therefor, 
so that the indiscriminate filing of lawsuits may be discouraged, without depriving a litigant of 
the benefit of proceeding  in forma pauperis if he/she is entitled to do so. 
 
 
         	
_____________________________ 
                              Mover’s Signature  	
 
 
  	
SWORN TO AND SUBSCRIBED BEFORE ME, a Notary Public in _______________, 
Louisiana, this _____ day of _______________, 200___. 
 
 
       _____________________________________ 
                      NOTARY PUBLIC 	
   	
 
 
Revised October 2003                                                                         \
                                                                                                        \
   Page 3  o	
 f 4

THIRD PARTY AFFIDAVIT	
 	
 
 
 	
STATE OF LOUISIANA 
PARISH OF 	
_________________________________	 	
 
 
   BEFORE ME , personally came and appeared: ______________________________, 
who, after being sworn, deposed and said that he/she knows _____________\
_____________, 
well and that he/she knows that because of his/her poverty and want of m\

eans, he/she is unable 
to pay the costs of court in advance or as they accrue, nor is he/she ab\
le to provide bond therefor. 
 
 
         _____________________________ 
          Signature of Witness  
 
 
    SWORN TO AND SUBSCRIBED BEFORE ME, a Notary Public in ______________, 
Louisiana, this ____day of _____________, 200___. 
 
 
       _______________________________________ 
             NOTARY PUBLIC 
 
 
 
 	
LEGAL SERVICE PROGRAMS’ DECLARATION	 	
 
       I ATTEST  that I am a duly authorized representa tive of a Legal Services Program funded 
by the Legal Service Corporation  or a Pro Bono Project  that receives referrals from one of these 
Legal Service Programs, and th at ________________________________ has produced evidence 
that he/she receives public assistance benefits, or  that he/she has qualified to receive free legal 
services based on his/her income being less than  or equal to 125% of the federal poverty level 
and therefore is entitled to a rebuttable presumpti on that he/she is entitled to the privilege of 
litigating without prior payment of costs. 
 
      ________________________________________________ 
                                                           Legal Service\
s Program or Pro Bono Project Representative 
 
 
 
 	
ORDER	 	
 	
Considering the foregoing Pleading and Affidavits: 
let _______________________________  prosecute or defend this litigation\
 in accordance with 
Louisiana Code of Civil Procedure, Article 5181,  et. seq., without paying the costs in advance or 
as they accrue or furnishing security therefor. 
  
  THUS, READ AND SIGNED,  this ______ day of _______________, 200___, in 
_________________, Louisiana. 
 
                                   
                                                                        \
              ___________________________________ 
   DISTRICT JUDGE 	
 	 
 
 
 
 
 
 
 
 
 	
Revised October 2003                                                    \
                                                	
                                                                        \
         Page 4  of  4 
 
 
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