Form J - In Forma Pauperis Form Page 3
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414. Please list any credit cards that you have:
Card type / name
Monthly payment
______________________________________________________
__________________________
______________________________________________________
__________________________
______________________________________________________
__________________________
______________________________________________________
__________________________
15. Please list any financial loans that you have:
Financial institution name / loan type
Monthly payment
______________________________________________________
__________________________
______________________________________________________
__________________________
______________________________________________________
__________________________
______________________________________________________
__________________________
______________________________________________________
__________________________
16. Does anyone regularly help pay your expenses? ______ If so, state the person’s name and relationship to
you: ___________________________________________________________________________________
17. Please state any additional income or assets not reported above: ______________________________
________________________________________________________________________________________
18. If you have an attorney, what arrangement have you made to pay the attorney fee, and what amount have
you paid? _______________________________________________________________________________
________________________________________________________________________________________
19. Do you understand that you may go to jail if you give false information on this form? _______________
AFFIDAVIT OF MOVER
PARISH OF ___________________________________
STATE OF LOUISIANA
BEFORE ME, the undersigned Notary Public, duly commissioned and qualified in this state and
parish, personally appeared ___________________________________, who after being sworn, declared:
1. that he/she provided the information above, and that the information is furnished to the Court for the
purpose of requesting permission to litigate the above captioned lawsuit without paying the costs in advance
or as they accrue, or furnishing security therefor;
2. that the above information is a true and correct statement of his/her information; and
3. that he/she has read and understands the privilege contained in the notice below.
NOTICE: Although you may be granted the privilege of proceeding without prepayment of costs, should a
judgment be rendered against you, your status as a pauper does not relieve you of the obligation to pay these
costs. The privilege to proceed in forma pauperis is restricted to litigants who are clearly entitled to do so,
with due regard to the nature of the proceeding, the court costs which otherwise would have to be paid, and
the ability of the litigant to pay them, or to furnish security therefor, so that the indiscriminate filing of
lawsuits may be discouraged, without depriving a litigant of the benefit of proceeding in forma pauperis if
he/she is entitled to do so.
___________________________________
Mover Signature
SWORN TO AND SUBSCRIBED before me this ____ day of ________________________, 20___, at
_________________________, Louisiana.
___________________________________
NOTARY PUBLIC
THE FAMILY COURT
FORM J, p. 3 of 4
REVISED: NOV 2013
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