Versus Number District Office of Workers' Compensation Administration State of Louisiana ...................................................................................................................... REQUEST FOR WAIVER OF PAYMENT OF ADVANCE COSTS FACTS CONCERNING THE EMPLOYEE *ALL QUESTIONS MUST BE ANSWERED COMPLETELY 1. FULL NAME: (First) (Middle/Maiden) (Last) 2. ADDRESS: (Street or Box) SOCIAL SECURITY #: HOME PHONE #: (City, State, Zip) 3. 4. MARITAL STATUS: Single Separated Widowed Married Divorced FURNISH THE FOLLOWING INFORMATION IF YOU ARE PRESENTLY EMPLOYED. IF UNEMPLOYED, GIVE INFORMATION REGARDING YOUR PAST EMPLOYER: Name of Employer: Check One: Present Monthly $ No Your Spouse's Weekly $ Monthly Payments $ No Monthly Payment $ Past Monthly $ 5. 6. 7. 8. WAGES: Yours Weekly $ ARE YOU BUYING YOUR HOME: Yes DO YOU OWN OR HAVE INTEREST IN ANY OTHER LAND? Yes IF ANSWERS TO QUESTIONS 6 AND 7 ARE YES, STATE THE NATURE OF THE PROPERTY AND VALUE. . IF NOT PURCHASING, WHAT IS YOUR MONTHLY HOME RENTAL? $ HAVE YOU SIGNED ANY CONTRACT WITH ANYONE WHEREIN YOU HAVE ASSIGNED OR TRANSFERRED YOUR CLAIM TO ANYONE ELSE? Yes No NAME OF ATTORNEY OTHER 9. 10. 11. DO YOU OWN, HAVE AN INTEREST IN OR ARE PURCHASING ANY OF THE FOLLOWING: Automobile Motorcycle/Bicycle Boat of any kind Furniture Livestock Paintings Machinery Stamp or coin collection Stocks Bonds, Notes or T-Bills Precious metal of any kind Certificates of Deposit Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No SAVINGS $ Value Value Value Value Value Value Value Value Value Value Value Value 12. DO YOU HAVE A BANK ACCOUNT: Yes IF YES, GIVE AMOUNT IN CHECKING $ American LegalNet, Inc. www.USCourtForms.com 13. DO YOU OWN ANY OF THE ABOVE IN SOMEONE ELSE'S NAME? YES NO EXPLAIN . 14. LIST EVERY ITEM OF INCOME YOU HAVE AS WELL AS SOURCE: 15. IS ANYONE DEPENDENT UPON YOU FOR SUPPORT: YES TO YOU. LIST ALL YOUR MONTHLY LIVING EXPENSES: NO . IF YES, STATE NAME, AGE AND RELATIONSHIP . 16. Laundry & Cleaning $ Food $ Personal/Grooming $ Housing$ Housing Supplies $ Educational Exp $ Clothing $ School $ Transportation $ Lunch $ Books $ Medical/Dental$ Utilities: Electricity $ Gas $ Water $ Phone $ Insurance $ Misc $ Fixed Obligations (Finance Company, Bank Loans, etc.): Company Monthly Payment $ $ $ 17. LIST ALL OTHER DEBTS YOU HAVE: Name of Creditor Monthly Payment $ $ $ $ 18. DO YOU HAVE ANY INTEREST IN A SUCCESSION WHICH MAY BE OR IS OPEN? YES NAME OF SUCCESSION DO YOU HAVE ANY LITIGATION OF ANY KIND PENDING IN THIS OR ANY OTHER COURT? YES DO YOU HAVE ANY INCOME OR ASSETS WHICH ARE NOT SHOWN ABOVE? LIST IN DETAIL. NO Amount Owed Balance 19. 20. NO VERIFICATION: I HEREBY VERIFY THAT I, , am the person who furnished the information contained in the above form; that I have signed saying that the information contained therein is true and correct; that the information is being furnished to the Office of Workers' Compensation to authorize the Workers' Compensation Judge thereof to permit my appearance to proceed in the above captioned matter. I further understand that the answers herein are continuous and if I ever acquire any assets described herein, I may be interrogated at any stage of these proceedings to inquire into my financial condition. EMPLOYEE'S SIGNATURE ATTESTING WITNESS: I, , know is the mover in the above captioned matter, and know (his/her) financial condition because (give reason you know financial condition) I firmly believe that (he/she) is unable to pay costs in this cause in advance or as they accrue or to furnish security thereof. I HAVE READ THE ABOVE VERIFICATION PARTY ATTESTING American LegalNet, Inc. www.USCourtForms.com ORDER Upon consideration of the foregoing request, supporting attestation and verification, it is ordered that Mover, , be permitted to file all pleadings/claims, appear in, and prosecute or defend in this action without advance payment of costs or as they may accrue, and without giving bond for costs. Louisiana this day of , 20 Workers' Compensation Judge Revised 1/1/98 American LegalNet, Inc. www.USCourtForms.com