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 versus COURT COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : Date thisIndex No. form is completed: : Calendar No. FORMA PAUPERIS APPLICATION : Plaintiff(s) ALL QUESTIONS MUST BE ANSWERED IN FULL. COMPLETE JUDICIAL CONCERNING MOVER. ALL FACTS SUBPOENA -against: 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. Defendant(s) : . .My .name.is:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ... . first 2. middle last My address and telephone number is: THE PEOPLE OF THE STATE OF NEW YORK Street Address: Mailing Address: TO City, state and zip code: Telephone number: 3. 4. 5. Apt. My date of birth GREETINGS: is: My social security number is: - - WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the widowed Court .My marital status is: (check one) married single separated divorced located at County of in room , on the day of with another20 if my at , as , spouse o'clock in the noon, and at any recessed living or adjourned date, to testify and give evidence as a witness in this action on the part of the 6. My occupation, employer and employer’s address is (if more than one, list all): Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. PART II: 7. Witness, Honorable Court in County, I am receiving financial assistance under one or more of the following programs: day of , one of the Justices of the , 20 (a) SSI or SSP (Supplemental Security Income or State Supplemental Payments Program) (b) AFDC or TANF (Aid to Families with Dependent Children Program or Temporary Aid to Needy Families) (Attorney must sign above and type name below) © Food Stamps (The Food Stamp Program) (d) City or Parish Relief, General Relief or General Assistance 8. 9. Attorney(s) for 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. Office and P.O. I am not able to pay any of the court costs or fees in advance or as they accrue. Address Signature of Mover Telephone No.: WARNING: You must immediately tell the Court if you become able to pay court costs or fees in advance or as they accrue during Facsimile No.: this action. You may be ordered to appear in Court and answer questions about your ability to pay court costs and fees. E-Mail Address: Mobile Tel. No.: Page 1 of 4 Pages American LegalNet, Inc. www.USCourtForms.com PART III: FINANCIAL INFORMATION 10. 11. 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) My gross monthly pay is: $ (e) MY TOTAL MONTHLY INCOME IS: © plus (d): (b) My payroll deductions are: (state purpose and amount) (f) The number of dependents, including me, supported by this money is: COURT COUNTY .OF . . . . . . . . (1) . . . . . . . . . . . . . $ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (2) $ (g) My spouse's occupation and employer is: : Index No. (3) $ (4) $ My TOTAL payroll deduction amount is: $ : (h) Calendar No. My spouse's gross monthly income is: :$ JUDICIAL SUBPOENA Plaintiff(s) (c) My monthly take-home pay is: -against(a) minus (b): $ (d) Other money I get each month is (Examples: workers compensation, Interest, Dividends, rent, Spousal Support, Child Support, Social Security, Retirement): Defendant(s) : : : : ...................................................... (1) (2) $ $ NOTE:THE PEOPLE OF THE10 and/or No. 11, attach a copy of your most recent paycheck or paystub, and if applicable, that of If you answered item No. STATE OF NEW YORK your spouse. 12. 13. TO 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: GREETINGS: (a) Rent or house payments & maintenance: (d) (j) Clothing: $ Transportation and/or auto expenses (insurance, gas, WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before $ repair): $ , the Honorable at the Court located at County ofFood & household supplies: $ (b) (k) Installment payments (state purpose and amount): in room , on the day of , 20 , at o'clock in the noon, and at any recessed Utilities & telephone: $ (1) or© adjourned date, to testify and give evidence as a witness in this action on the part of the$ (2) (3) $ $ (e) Laundry: $ The TOTAL contempt of court and will payments Your failure to comply with this subpoena is punishable as a amount of monthly installmentmake you liable to is: $ the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a (f) Medical Expenses: $ result of your failure to comply. (l) (g) Court in Insurance (life, health, accident, etc.): Witness, Honorable $ County, (h) , one of the Justices of the , 20 (m) Child & spousal support: $ Other expenses (specify): School & child care: $ (I) day of Amounts deducted due to garnishments, wage assign ments and earnings withholding orders: $ (1) $ (2) $ (Attorney must sign above and type name below) (3) $ (4) $ (5) $ (6) $ Attorney(s) for The TOTAL amount of other monthly expenses is: $ Office and P.O. Address (n) MY TOTAL MONTHLY EXPENSES ARE (add (a) through (m): $ Telephone No.: Facsimile No.: Signature of Mover E-Mail Address: Mobile Tel. No.: Page 2 of 4 Pages American LegalNet, Inc. www.USCourtForms.com 14. I own or have an interest in the following property: (a) Cash: $ (d) (b) Checking or savings accounts at any financial institution: $ Real estate (list address, estimated fair market value, and equity of each property): (1) $ $ (2) (3) (c) (1) (2) (3) $ $ $ (e) Cars, other vehicles and boat (list make and year of each) and estimated value: COURT 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.: $ COUNTY .OF . . . . . . . . (1) . . . . . . . . . . . . . . . . . $ . . . . . . . . . . . . . . . . . . . . . . . . . . . . : (2) (3) $ $ $ $ : Index No. Calendar No. 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 Plaintiff(s) of all such matters.): : JUDICIAL SUBPOENA -against- : : 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.): : 16. Defendant(s) : ...................................................... 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. THE PEOPLE OF THE STATE OF NEW YORK TO Signature of Mover STATEMENT OF ATTORNEY GREETINGS: 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. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of ATTORNEY'S SIGNATURE in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the PRINT NAME BAR NUMBER: TEL. NO.: Your affidavit" required to be this subpoena is punishable that of a "pecuniarily disinterested" person. This NOTE: The "supportingfailure to comply with submitted herein above must beas a contempt of court and will make you liable to the party on whose behalf this subpoena was issued any member of the attorney's $50 or the spouse or minor child as preludes the participation of the attorney, and ordinarily precludesfor a maximum penalty of staff, and all damages sustainedof a result of your An appropriate reprimand for improper use of this procedure may result in a monetary sanction. the indigent declarant. failure to comply. Witness, Honorable County, STATECourt in OF LOUISIANA AFFIDAVIT OF MOVER day of , one of the Justices of the , 20 PARISH OF BEFORE ME, the undersigned authority, personally came and appeared, (Attorney must sign above and type name below) 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 Attorney(s) for 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. Office and P.O. Address SWORN TO AND SUBSCRIBED BEFORE ME, this day of Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: NOTARY PUBLIC Page 3 of 4 Pages Mover American LegalNet, Inc. www.USCourtForms.com AFFIDAVIT OF PERSON SUPPORTING MOVER'S PAUPER STATUS STATE OF LOUISIANA PARISH OF 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. COURT (He)(She) knows that it is a crime to intentionally swear to what is known to be a false answer. COUNTY OF ...................................................... : SWORN TO AND SUBSCRIBED BEFORE ME, this Index No.READ THE ABOVE AFFIDAVIT I HAVE : day of Plaintiff(s) NOTARY PUBLIC -against- Calendar No. : JUDICIAL SUBPOENA PARTY SWEARING : : : ORDER Defendant(s) : . .The. foregoing . . . . . . .supporting .affidavits. and. sworn.facts.considered, let Mover . . . . . . . . . motion, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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, THE et seq., as amended, pending OF NEW YORK Articles 5181PEOPLE OF THE STATE further orders of this Court. TO NEW ORLEANS, LOUISIANA, this day of JUDGE GREETINGS: PROCEDURES IN FORMA PAUPERIS WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Sectionthe Before any judicial proceedings are permitted to be prosecuted or defendedCourt to Louisiana Code of Civil Procedure, 1. Honorable pursuant , at the 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 located at County of 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. in room , on the day of , 20 , at o'clock in the noon, and at any recessed 5183(2) by inquiring into the facts and satisfying itself that the applicant is entitled to the privilege. or adjourned date, to testify and give evidence as a witness in this action on the part of the 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 Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Division to which the case was allotted, a motion which shall be tried contradictorily with the adverse party(ies) to the end that the the party on whose behalf this subpoena was issued sectionmaximum penalty of to theand all or to the party who may a for a is to minimize the cost $50 public damages sustained as actual necessity for same may be determined. The purpose of this result cast for cost but without in any way prejudicing such litigant's cause or rights accorded the litigant by Louisiana Code of of your failure to comply. ultimately be 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 Witness, Honorable a reporter on its staff. furnish same utilizing , one of the Justices of the Court in County, day of , 20 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 (Attorney must sign above and type name below) 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 Attorney(s) for 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. Office and P.O. Address I certify that I have read the foregoing procedures, Sections 1 through 5. Telephone No.: SIGNATURE OF PARTY OR LAWYER Facsimile No.: E-Mail Address: Mobile Tel. No.: Page 4 of 4 Pages American LegalNet, Inc. www.USCourtForms.com