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 f 4 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 http://www.lasc.org/rules/dist.ct/COURTRULESAPPENDIX8.0.PDF
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