CIVIL DISTRICT COURT FOR THE PARISH OF ORLEANS FIRST CITY COURT OF THE CITY OF NEW ORLEANS SECOND CITY COURT OF THE CITY OF NEW ORLEANS STATE OF LOUISIANA NO. SECTION DIVISION
Date this form is completed: FORMA PAUPERIS APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN FULL. COMPLETE ALL FACTS CONCERNING MOVER.
NOTE: If more than one person is seeking pauper status, each person must complete a separate form. I request a court order so that I do not have to pay court costs and fees in advance or as they accrue. PART 1: 1. My name is: first 2. My address and telephone number is: Street Address: Mailing Address: City, state and zip code: Telephone number: 3. 4. 5. My date of birth is: My social security number is: .My marital status is: (check one) married single widowed separated divorced Apt. middle last
living with another as if my spouse 6. My occupation, employer and employer's address is (if more than one, list all):
PART II: 7. (a) (b) © (d) 8. I am receiving financial assistance under one or more of the following programs: SSI or SSP (Supplemental Security Income or State Supplemental Payments Program) AFDC or TANF (Aid to Families with Dependent Children Program or Temporary Aid to Needy Families) Food Stamps (The Food Stamp Program) City or Parish Relief, General Relief or General Assistance If you checked a box in item No. 7 above, you must attach documents to verify receipt of the benefits checked. If you have checked a box in Item No. 7 above, sign on the following line and only complete the affidavits at the end of this form. I am not able to pay any of the court costs or fees in advance or as they accrue.
Signature of Mover WARNING: You must immediately tell the Court if you become able to pay court costs or fees in advance or as they accrue during this action. You may be ordered to appear in Court and answer questions about your ability to pay court costs and fees. Page 1 of 4 Pages
PART III: FINANCIAL INFORMATION 10. My pay changes considerably from month to month. (If you checked this box, each amount reported in item No. 10 should be your monthly average for the past 12 months.) My monthly income: (a) (b) My gross monthly pay is: $ My payroll deductions are: (state purpose and amount) (1) $ (2) $ (3) $ (4) $ My TOTAL payroll deduction amount is: $ (c) My monthly take-home pay is: (a) minus (b): $ Other money I get each month is (Examples: workers compensation, Interest, Dividends, rent, Spousal Support, Child Support, Social Security, Retirement): (1) (2) $ $ (e) MY TOTAL MONTHLY INCOME IS: © plus (d):
The number of dependents, including me, supported by this money is: My spouse's occupation and employer is:
My spouse's gross monthly income is: $
NOTE: If you answered item No. 10 and/or No. 11, attach a copy of your most recent paycheck or paystub, and if applicable, that of your spouse. 12. I am represented in this case by a volunteer attorney (examples: NOLAC, Legal Aid, ProBono Project, Law School Clinic). My monthly expenses not already listed in item No. 11 above are: (a) Rent or house payments & maintenance: $ Food & household supplies: $ Utilities & telephone: $ Clothing: $ Laundry: $ Medical Expenses: $ (l) (g) Insurance (life, health, accident, etc.): $ (m) (h) (I) School & child care: $ Child & spousal support: $ (1) (2) (3) (4) (5) (6) $ $ $ $ $ $ Amounts deducted due to garnishments, wage assign ments and earnings withholding orders: $ Other expenses (specify): (j) Transportation and/or auto expenses (insurance, gas, repair): $ Installment payments (state purpose and amount): (1) (2) (3) $ $ $
(b) © (d) (e) (f)
The TOTAL amount of monthly installment payments is: $
The TOTAL amount of other monthly expenses is: $ (n) MY TOTAL MONTHLY EXPENSES ARE (add (a) through (m): $
Signature of Mover
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I own or have an interest in the following property: (a) (b) Cash: $ Checking or savings accounts at any financial institution: $ (d) Real estate (list address, estimated fair market value, and equity of each property): $ (2) (3) (c) (1) (2) (3) $ $ $ $ $ $ $ $
Cars, other vehicles and boat (list make and year of each) and estimated value: (1) (2) (3) 15. $ $ $
Other property such as jewelry, furniture, furs, art, stocks, bonds, certificates of deposit, coin or stamp collections, U. S. Savings Bonds, annuities, IRA, etc.: $
I have an interest in an estate or succession which may be or is opened and or an interest in other civil litigation. (State the name, court, and case number of all such matters.):
Other facts which support this application (describe unusual medicals, needs, expenses for recent family emergencies or other unusual expenses to help the Court understand your budget-, if more space is needed, attach a page labeled attachment 16.):
WARNING: You must immediately tell the Court if you become able to pay court costs or fees in advance or as they accrue during this action. You may be ordered to appear in Court and answer questions about your ability to pay court costs and fees.
Signature of Mover STATEMENT OF ATTORNEY I, the undersigned attorney, duly admitted to practice in the State of Louisiana, do hereby declare and affirm that I have carefully reviewed the above and foregoing statement of my client and approve the client having submitted the same.
ATTORNEY'S SIGNATURE PRINT NAME BAR NUMBER: TEL. NO.: NOTE: The "supporting affidavit" required to be submitted herein above must be that of a "pecuniarily disinterested" person. This preludes the participation of the attorney, and ordinarily precludes any member of the attorney's staff, or the spouse or minor child of the indigent declarant. An appropriate reprimand for improper use of this procedure may result in a monetary sanction. AFFIDAVIT OF MOVER STATE OF LOUISIANA BEFORE ME, the undersigned authority, personally came and appeared, who after being duly sworn, deposed and said that (he) (she) is the person who furnished the information contained in the above form; that (he) (she) has signed same; and that the information contained therein is true and correct; that this information is being furnished to the Orleans Parish Civil District Court for the purpose of obtaining an order to proceed in the above captioned lawsuit pursuant to LA C.C.P. Arts. 5181 et seq., and mover is prepared to appear in Court to give any information which may be desired in addition to the above. Mover further understands that the answers herein are continuous and if Mover ever acquires any assets described herein Mover will make the fact known prior to trial of this matter. Mover agrees to be further interrogated at any stage of these proceedings to inquire into Mover's financial condition. Mover knows it is a crime to intentionally swear to a known false answer. SWORN TO AND SUBSCRIBED BEFORE ME, this day of Mover NOTARY PUBLIC Page 3 of 4 Pages PARISH OF
AFFIDAVIT OF PERSON SUPPORTING MOVER'S PAUPER STATUS
STATE OF LOUISIANA
BEFORE ME, the undersigned authority, personally came and appeared, who, being duly sworn, deposed and said: That (he) (she) knows who is the mover in the above captioned matter and knows (his)(her) financial condition because:
(Basis of knowledge stated in detail.)
and (he) (she) family believes that (he) (she) is unable to pay costs in this cause in advance or as they accrue or to furnish security. (He)(She) knows that it is a crime to intentionally swear to what is known to be a false answer. I HAVE READ THE ABOVE AFFIDAVIT SWORN TO AND SUBSCRIBED BEFORE ME, this day of PARTY SWEARING
ORDER The foregoing motion, supporting affidavits and sworn facts considered, let Mover be permitted to file all pleadings, appear in, and prosecute or defend in this action without prior payment of costs or as they accrue, and without giving bond for costs, as provided by laws of the State of Louisiana and particularly Louisiana Code of Civil Procedure, Articles 5181 et seq., as amended, pending further orders of this Court. NEW ORLEANS, LOUISIANA, this day of
JUDGE PROCEDURES IN FORMA PAUPERIS Section 1. Before any judicial proceedings are permitted to be prosecuted or defended pursuant to Louisiana Code of Civil Procedure, Articles 5 18 1, et seq. (Waiver of Costs for Indigent Party), the applicant and the affiant attesting to the applicant's inability to pay the costs of court, may be required to appear before the Judge assigned the case so that the Court may properly comply with C.C.P. art. 5183(2) by inquiring into the facts and satisfying itself that the applicant is entitled to the privilege. Section 2. Should counsel for any litigant who has been permitted to prosecute or defend in forma pauperis desire to take action in the cause which would increase the expense over and above those normally attendant to trial and appeal, such as, but not limited to, the taking of depositions to be used in lieu of a witness' testimony or otherwise, counsel shall first present to the judge presiding over the Division to which the case was allotted, a motion which shall be tried contradictorily with the adverse party(ies) to the end that the actual necessity for same may be determined. The purpose of this section is to minimize the cost to the public or to the party who may ultimately be cast for cost but without in any way prejudicing such litigant's cause or rights accorded the litigant by Louisiana Code of Civil Procedure, Article 518 1, et seq. If the purpose of the motion is to secure reporting services outside the courtroom, the Court, in its discretion, may furnish same utilizing a reporter on its staff. Section 3. In the event a judicial proceeding is filed and sought to be prosecuted in forma pauperis and the court refuses to permit the applicant to so proceed, the court shall order that the applicant be allowed fifteen (15) days within which to advance the necessary costs and in default of same may dismiss, without prejudice, the proceeding. In the further event that an applicant does not within fifteen (15) days from date of denial seek a hearing thereof, the proceeding may be dismissed without prejudice upon ex parte motion of any party at interest. Section 4. Any part or all of these procedures may be waived by the court when the applicant is in the custody of the Department of Corrections or is otherwise incarcerated. Such other or additional requirements for proceeding in forma pauperis may be Section 5. This form shall be used in all paper proceedings filed after April 30, 1998. Prior to April 30, 1998, the previous forma pauperis affidavit provided by the Clerk of Court may be used in lieu of this form. I certify that I have read the foregoing procedures, Sections 1 through 5.
SIGNATURE OF PARTY OR LAWYER
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