Louisiana > Local Parish > East Baton Rouge > City Court > Civil
Motion To Proceed In Forma Pauperis - Louisiana
| Motion To Proceed In Forma Pauperis Form. This is a Louisiana form and can be used in Civil City Court East Baton Rouge Local Parish . |
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______________________________________ 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) American LegalNet, Inc. www.FormsWorkFlow.com 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) American LegalNet, Inc. www.FormsWorkFlow.com 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_______ (If yes, explain Income source and amount received monthly, or the asset type and total value below) Yes_______ Amount Received Monthly (if an income) List the Asset Type or Income Source (If S.S.I., Social Security, etc, state how much) 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 American LegalNet, Inc. www.FormsWorkFlow.com 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) American LegalNet, Inc. www.FormsWorkFlow.com 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 R
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