In Forma Pauperis Affidavit (Louisiana) Page 2
Download a blank fillable In Forma Pauperis Affidavit (Louisiana) in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete In Forma Pauperis Affidavit (Louisiana) with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
48(a). If you are married and live with a spouse, please answer:
Is your spouse employed?_______ What is the occupation of your spouse?_______________
Is your spouse paid Weekly? ___ Bi-Weekly? ___ Monthly? ___ Amount/month $_________
Name of spouse’s employer:_____________________________________________________
Address: ____________________________________________________________________
(Street Address)
(City and State)
(Zip Code)
Telephone Number: __________________ How long has spouse been employed? ________
8(b). Do you or your spouse receive any of the following income or support? __YES __ NO
If yes, state the monthly amount. SSI: $____________ Disability: $_____________
Worker’s Comp: $____________
Unemployment Benefits: $________
Food Stamps: $_____________ TANF: $_____________ Child Support: $____________
Spousal Support: $ _________
$__________
Other: $________
Kinship Care Subsidy Grant:
If you are a client of a legal services program funded by the Legal Service Corporation or a
Pro Bono Project that receives referrals from a legal services program and have a
combined income from questions 7 and 8 that is less than or equal to 125% of the federal
poverty level, skip all parts of question 9, and continue with question 10 on the next page.
9. Do you own or have an interest in any of the following?
)
(Including community property
A.
VALUE OF INTEREST
BALANCE OWED
HOUSE
$
$
AUTOMOBILE
$
$
TRUCK
$
$
WATERCRAFT
$
$
LIVESTOCK
$
$
MACHINERY
$
$
STOCK
$
BONDS
$
CERTIFICATES OF DEPOSIT
$
Equity
Debt
OTHER IMMOVABLE PROPERTY
$
$
DO YOU HAVE A BANK ACCOUNT(S)? __YES __ NO Amount in account(s): $________
___CHECKING ____SAVINGS
Name and Location of Bank: ____________________________
TOTAL VALUE OF ASSETS: $ ___________
B. i. List your Monthly Expenses:
Rent: $
Cable: $
Car Note: $
Lot Rent: $
Garbage: $
Car Insurance: $
House Note: $
Medical Insurance: $
Transportation: $
House Insurance: $
Medical Expenses: $
Food: $
Gas: $
Dental Expenses: $
Barber/ Beauty: $
Electricity: $
Prescriptions: $
Entertainment: $
Water: $
Life Insurance: $
Grooming Supplies: $
Telephone: $
Daycare: $
Garnishment: $
Property Taxes: $
Child Support: $
Other: $
Total Amount of section i:
$___________
ii. Credit cards:
(List type of card and monthly payment)
Card Name
Monthly Payment
$
$
$
$
Total Amount of section ii:
$___________
iii. Financial Loans:
(List the financial institution and your monthly payment)
Financial Name
Monthly Payment
Total Amount of section iii:
$___________
TOTAL MONTHLY EXPENSES:
$___________
(Add 9B (i+ii+iii) =Total Monthly Expenses)
Revised October 2003
Page 2 of 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal