______________________________________ SUIT NO: ________________ PLAINTIFF VS. 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: SS# Street Address: City: State Zip Home Phone No.: Birth Date: Place of Birth 2. Marital Status: Single: 3. (Check one) Married: Separated: Divorced: Widowed: (If currently employed, supply the following information) Your Employer : Street Address: City: State Employer Phone : Length of Employment Your Wages: 4. Weekly $ Zip Monthly $ (If married and living with spouse, supply the following information) Spouse’s Name: Spouse’s Employer: Street Address: City: State Employer Phone : Length of Employment Spouse’s Wages: 5. Weekly $ Zip Monthly $ (If buying your home, state the location, value and balance owed) Home Street Address: City: State Home Value $ 6. Zip Full Balance Owed $ (State the Nature and Value of any other LAND(s) in which you own an interest) Property 1: Property 2: Property 3: Civil – Motion To Proceed In Forma Pauperis (10-06-05) Total Value $ Total Value $ Total Value $ Monthly Income $ Monthly Income $ Monthly Income $ 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) Asset Type NO Total value (of YOUR interest) YES Automobile(s) $ Boat(s) $ Livestock $ Machinery $ Stocks $ Bonds $ Certificates of Deposit $ Bank Accounts $ Savings Accounts (if you receive an income) $ Mobile Home (s) Amount Received Monthly $ 8. Do you have any assets or income not shown above? No_______ Yes_______ (If yes, explain Income source and amount received monthly, or the asset type and total value below) List the Asset Type or Income Source Total Value (If S.S.I., Social Security, etc, state how much) (if an asset) Amount Received Monthly (if an income) $ $ $ $ $ $ $ $ No _______ 9. Is anyone dependent upon you for support? Yes _______ (If yes, state their names, ages, and relationship) Name of Dependant Age Relationship to You 10. List any Credit Card debts you may have: Name of Credit Card Total Balance Owed (i.e. Visa, MasterCard, Sears, J.C. Penny, Etc.) Required Minimum Monthly Payment $ $ $ $ $ $ $ $ Civil – Motion To Proceed In Forma Pauperis (10-06-05) $ $ TOTALS $ $ $ 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 12. Your Total Monthly Income (add 3,4,6,7 and 8) $ 0.00 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 Rouge, Louisiana, on this _____ day of ________________, 20 _____. ___________________________________________ NOTARY PUBLIC Civil – Motion To Proceed In Forma Pauperis (10-06-05) American LegalNet, Inc. www.FormsWorkFlow.com ______________________________________ SUIT NO: ________________ PLAINTIFF VS. 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) American LegalNet, Inc. www.FormsWorkFlow.com ______________________________________ SUIT NO: ________________ PLAINTIFF VS. 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) American LegalNet, Inc. www.FormsWorkFlow.com