Free cr-1964.PDF - Louisiana

Rev. 7/93

UNITED STATES DISTRICT COURT WESTERN DISTRICT OF LOUISIANA

Plaintiff versus Defendant Civil Action No. / Judge Mag.Judge

APPLICATION TO PROCEED IN FORMA PAUPERIS UNDER SECTION 706(f) OF CIVIL RIGHTS ACT OF 1964 1. 2. FULL NAME ADDRESS (Street Address or P. O. Box) (City) 3. 4. MARITAL STATUS: Single Divorced (State) Married (Zip Code)

Separated Widowed

Are you presently employed? Yes No If the answer is "yes," give your occupation, the name and address of your employer and the gross and net amount of your salary. (Occupation) (Gross Salary) (Net Salary)

(Name and address of Your employer) 5. If you are not presently employed, state the date of your last employment, the name and address of your employer and your salary. (Date last employed) (Name and Address of last Employer) 1 (Salary)

6.

If you are married and if your spouse is employed, state his/her name, occupation, employer, address of employer and salary. (Name of spouse) (Occupation) (Salary)

7.

Approximately how much money have you received in the past twelve months from the following sources: as wages, salary, commissions or earned income of any kind? as workman's compensation or disability insurance? as rent payments, interest, dividends? as pensions, annuities or life insurance payments? from social payments? security, unemployment compensation or welfare

as gifts or inheritance? from other sources? 8. 9. How much money do you own or have in any checking or savings account? Do you own or have any interest in any real estate, automobiles or other vehicles, boats, stocks, bonds, notes, or any other valuable property (excluding ordinary household furnishings and clothing)? Yes _____ No _____ If "yes", give a description of the property and its estimated value.

10.

Is anyone dependent on you for support? Yes _____ No _____ If "yes", give names, ages, relationship to you, and the amount you contribute toward their support.

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11.

List any debts you have and the amount owed. Creditor Amount Owed

12.

List your monthly living expenses.

I certify under penalty of perjury that the above information is true and correct to the best of my knowledge. ___________________________________ (Signature of Applicant)

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Rev. 7/93

UNITED STATES DISTRICT COURT WESTERN DISTRICT OF LOUISIANA

Plaintiff versus Defendant Civil Action No. / Judge Mag.Judge

MOTION FOR APPOINTMENT OF COUNSEL UNDER SECTION 706(f) OF CIVIL RIGHTS ACT OF 1964 PART 1: EFFORTS TO OBTAIN COUNSEL

Declaring that the information I have given below is true and correct, I apply to the court for appointment of an attorney. A. Have you talked with any attorney about handling your claim? Yes No

If "yes", give the following information abut each attorney with whom you talked: Attorney When: How (by telephone, in person, etc.): Why was this attorney not employed to handle your claim?

Attorney When: How (by telephone, in person, etc.): Why was this attorney not employed to handle your claim?

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Attorney When: How (by telephone, in person, etc.): Why was this attorney not employed to handle your claim?

B. Explain any other efforts you have made to contact an attorney to handle your claim:

C. Give any other information which supports your application for the court to appoint counsel:

D. Name and address of each attorney who has represented you in the last ten (10) years:

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PART 2:

FINANCIAL INFORMATION

(DO NOT FILL THIS OUT IF YOU HAVE ALREADY SUPPLIED THIS INFORMATION IN THE APPLICATION TO PROCEED WITHOUT PREPAYING COSTS). 1. 2. FULL NAME ADDRESS (Street Address or P. O. Box) (City) (Telephone) 3. MARITAL STATUS: Single Divorced Married Separated Widowed (State) (Zip Code)

4.

Are you presently employed? Yes No If the answer is "yes," give your occupation, the name and address of your employer and the gross and net amount of your salary. (Occupation) (Gross Salary) (Net Salary)

(Name and address of Your employer) 5. If you are not presently employed, state the date of your last employment, the name and address of your employer and your salary. (Date last employed) (Name and Address of last Employer) 6. If you are married and if your spouse is employed, state his/her name, occupation, employer, address of employer and salary. (Name of spouse) (Occupation) (Salary) (Salary)

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7.

Approximately how much money have you received in the past twelve months from the following sources: as wages, salary, commissions or earned income of any kind? as workman's compensation or disability insurance? as rent payments, interest, dividends? as pensions, annuities or life insurance payments? from social payments? security, unemployment compensation or welfare

as gifts or inheritance? from other sources? 8. How much money do you own or have in any checking or savings account? $ Do you own or have any interest in any real estate, automobiles or other vehicles, boats, stocks, bonds, notes, or any other valuable property (excluding ordinary household furnishings and clothing)? Yes _____ No _____ If "yes", give a description of the property and its estimated value.

9.

10.

Is anyone dependent on you for support? Yes _____ No _____ If "yes", give names, ages, relationship to you, and the amount you contribute toward their support.

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11.

List any debts you have and the amount owed. Creditor Amount Owed

12.

List your monthly living expenses.

Under penalty of perjury, I declare that the information given in this complaint is true and correct. Date:______________________ ______________________________ Signature ______________________________ Street Address or P. O. Box ______________________________ City, State, Zip Code __________/___________________ Area Code / Telephone Number WITNESSES: ____________________________ ____________________________

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