Free Motion to Proceed in Forma Pauperis - Louisiana

______________________________________
PLAINTIFF VS.

SUIT NO: ________________ BATON ROUGE CITY COURT CITY OF BATON ROUGE

_____________________________________________
DEFENDANT

STATE OF LOUISIANA

MOTION TO PROCEED IN FORMA PAUPERIS
Mover, _________________________________________________________________________, is a citizen of the State of Louisiana and desires to avail (himself) (herself) of the benefits provided by law, in particular the Louisiana Code of Civil Procedure, Articles 5181-5188, as amended, and requests leave of this Court to proceed "in forma pauperis". Mover further alleges that (he) (she) is without means to pay costs in this litigation, either in advance or as they accrue, or to furnish security therefor. See attached fact sheet. Wherefore, Mover prays that the Court allow (him) (her) to proceed "in forma pauperis", as provided by the laws of the State of Louisiana.
SUBMITTED BY: (Name) ________________________________________________ (Address)

_______________________________________________

(City,State,Zip)_______________________________________________

STATE OF LOUISIANA PARISH OF EAST BATON ROUGE
BEFORE ME, personally came and appeared _____________________________________________________,

who, being duly sworn, did depose and say that (he) (she) is unable, because of (his) (her) poverty and want of means, to pay costs in advance or as they accrue or to furnish security therefor.
______________________________________________ MOVER (Signature)

SWORN TO AND SUBSCRIBED before me on the _____ day of________________, 20______ at Baton Rouge, Louisiana.

___________________________________________________
NOTARY PUBLIC

Civil ­ Motion To Proceed In Forma Pauperis (10-06-05)

FACTS CONCERNING MOVER
1. Mover's Full Name:
Street Address: City: Home Phone No.: Birth Date: Place of Birth State Zip SS#

2.

Marital Status:
Single:

(Check one) Married: Separated: Divorced: Widowed:

3. Your Employer :
Street Address: City: Employer Phone : Your Wages:

(If currently employed, supply the following information)

State Length of Employment Weekly $ Monthly $

Zip

4. Spouse's Name:
Spouse's Employer: Street Address: City: Employer Phone : Spouse's Wages:

(If married and living with spouse, supply the following information)

State Length of Employment Weekly $ Monthly $

Zip

5. Home Street Address:
City:

(If buying your home, state the location, value and balance owed)
State Home Value $ Full Balance Owed $ Zip

6. Property 1:
Property 2: Property 3:

(State the Nature and Value of any other LAND(s) in which you own an interest)
Total Value $ Total Value $ Total Value $ Monthly Income $ Monthly Income $ Monthly Income $

Civil ­ Motion To Proceed In Forma Pauperis (10-06-05)

7.

Do you own or have an interest in any of the following type assets?
(Mark each Asset Type as appropriate) Total value (of YOUR interest)

Amount Received Monthly
(if you receive an income)

Asset Type

NO

YES

Automobile(s) Mobile Home (s) Boat(s) Livestock Machinery Stocks Bonds Certificates of Deposit Bank Accounts Savings Accounts

$ $ $ $ $ $ $ $ $ $

8. Do you have any assets or income not shown above? No_______
List the Asset Type or Income Source
(If S.S.I., Social Security, etc, state how much)

(If yes, explain Income source and amount received monthly, or the asset type and total value below)

Yes_______
Amount Received Monthly
(if an income)

Total Value
(if an asset)

$ $ $ $

$ $ $ $

9. Is anyone dependent upon you for support?
(If yes, state their names, ages, and relationship)

No _______
Age

Yes _______
Relationship to You

Name of Dependant

10. List any Credit Card debts you may have:
Name of Credit Card
(i.e. Visa, MasterCard, Sears, J.C. Penny, Etc.)

Total Balance Owed $ $ $ $ $ $ $ $ $ $ $ $

Required Minimum Monthly Payment

TOTALS
Civil ­ Motion To Proceed In Forma Pauperis (10-06-05)

$

0.00

$

0.00

11. List your MONTHLY living expenses: Rent or Home Mortgage Utilities
Electricity Water/Sewer Telephone Other

$

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Food Clothing Laundry Medical/Dental
(not covered by insurance)

Transportation
(gasoline, etc.)

Recreation and Entertainment Charitable Contributions Insurance
Homeowners/Renters Life Insurance Health Insurance Auto Insurance

Installment Payments
Auto Payments Other Payments Other Payments

Alimony Child Support
Total Monthly Living Expenses

$

0.00

12. Your Total Monthly Income (add 3,4,6,7 and 8)

0.00 $________________

13. Has your attorney explained to you or are you aware that, if you have intentionally given a false answer to any of the above questions, you may have committed a crime that is punishable by incarceration. (R.S. 14:123) Yes __________ No _________ __________________________________________
MOVER (Signature)
Civil ­ Motion To Proceed In Forma Pauperis (10-06-05)

STATE OF LOUISIANA PARISH OF EAST BATON ROUGE

BEFORE ME, the undersigned authority, personally came and appeared ___________________________

_________________________________________, who, after being duly sworn, deposed and said (he) (she) is the person who furnished the information contained in the above form; that (he) (she) has signed same; that the information contained therein is true and correct; that this information is being furnished to the Baton Rouge City Court for the purpose of inducing a Judge thereof to permit appearers to proceed in the above captioned lawsuit pursuant to La. C.C.P. Article 5181 et. seq.

_____________________________________________ MOVER (Signature)

SWORN TO AND SUBSCRIBED before me, Notary Public, at Baton Rouge, Louisiana, on this ____ day

of __________________, 20 _____. ___________________________________________
NOTARY PUBLIC

STATE OF LOUISIANA PARISH OF EAST BATON ROUGE
BEFORE ME, the undersigned authority, personally came and appeared _______________________________________,

who, being duly sworn, deposed and said: That (he) (she) is fully acquainted with ______________________________________________, who is the Mover in the above captioned matter and knows (his) (her) financial condition, and (he) (she) firmly believes that (he) (she) is unable to pay costs in this cause in advance or as they accrue or to furnish security therefor.

___________________________________________
ACQUAINTANCE (Signature)

SWORN TO AND SUBSCRIBED before me, Notary Public, at Baton Rouge, Louisiana, on this _____ day

of ________________, 20 _____.
___________________________________________
NOTARY PUBLIC

Civil ­ Motion To Proceed In Forma Pauperis (10-06-05)

______________________________________
PLAINTIFF VS.

SUIT NO: ________________ BATON ROUGE CITY COURT CITY OF BATON ROUGE

_____________________________________________
DEFENDANT

STATE OF LOUISIANA

ORDER
Considering the foregoing Motion, supporting affidavit, and sworn facts , let _________________________________________________________________________ be permitted to file all pleadings, appear in, and prosecute or defend this action without prior payment of costs or as they accrue and without giving bond for costs, as provided by the law of the State of Louisiana and, particularly, Louisiana Code of Civil Procedure Article 5181 et seq., as amended.

Baton Rouge, Louisiana, on this _______ day of __________________________ 20 ________ .

__________________________________________
JUDGE, BATON ROUGE CITY COURT, DIV.____

Civil ­ Motion To Proceed In Forma Pauperis (10-06-05)

______________________________________
PLAINTIFF VS.

SUIT NO: ________________ BATON ROUGE CITY COURT CITY OF BATON ROUGE

_____________________________________________
DEFENDANT

STATE OF LOUISIANA

ORDER Considering the foregoing Motion, supporting affidavit, and sworn facts, the request for pauper status is denied, and said petitioner is hereby granted __________ days from the date of the signing of this Order to pay the fees associated with the filing of these pleadings.

Baton Rouge, Louisiana, on this _______ day of __________________________ 20 ________ .

_________________________________________________ JUDGE, BATON ROUGE CITY COURT, DIV.____

Civil ­ Motion To Proceed In Forma Pauperis (10-06-05)