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
STATE OF LOUISIANA
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 permission to litigate the above captioned lawsuit without
paying the costs in advance or as they accrue or furnishing security therefor.
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 m
eans, he/she is unable to pay the costs of court
in advance or as they accrue, nor is he/she able to provide security therefor.
4. He/She has read and understands the privilege contained in the notice below.
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.
SWORN TO AND SUBSCRIBED BEFORE ME, a Notary Public in _______________,
Louisiana, this _____ day of _______________, 200___.
Revised October 2003 Page 3 of 4