_____________________________ * _______ 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 protection 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:___ Divorced:___ Wi
dowed:___ 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:
Weekly?
____ 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: $_____________
Worker’s Com
p: $____________ 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, and 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 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.
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 of 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 means, he/she is unable
to pay the costs of court in advance or as they accrue, nor is he/she able 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 representative 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 that ________________________________ 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 presumption that he/she is entitled to the privilege of
litigating without prior payment of costs.
________________________________________________
Legal Services 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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