In Forma Pauperis Affidavit (Louisiana) Page 4
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4THIRD PARTY AFFIDAVIT
STATE OF LOUISIANA
PARISH OF
_________________________________
BEFORE ME, personally came and appeared: ______________________________,
who, after being sworn, deposed and said that he/she knows __________________________,
well and that he/she knows that because of his/her poverty and want of means, he/she is unable
to pay the costs of court in advance or as they accrue, nor is he/she able to provide bond therefor.
_____________________________
Signature of Witness
SWORN TO AND SUBSCRIBED BEFORE ME, a Notary Public in ______________,
Louisiana, this ____day of _____________, 200___.
_______________________________________
NOTARY PUBLIC
LEGAL SERVICE PROGRAMS’ DECLARATION
I ATTEST that I am a duly authorized representative of a Legal Services Program funded
by the Legal Service Corporation or a Pro Bono Project that receives referrals from one of these
Legal Service Programs, and that ________________________________ has produced evidence
that he/she receives public assistance benefits, or that he/she has qualified to receive free legal
services based on his/her income being less than or equal to 125% of the federal poverty level
and therefore is entitled to a rebuttable presumption that he/she is entitled to the privilege of
litigating without prior payment of costs.
________________________________________________
Legal Services Program or Pro Bono Project Representative
ORDER
Considering the foregoing Pleading and Affidavits:
let _______________________________ prosecute or defend this litigation in accordance with
Louisiana Code of Civil Procedure, Article 5181, et. seq., without paying the costs in advance or
as they accrue or furnishing security therefor.
THUS, READ AND SIGNED, this ______ day of _______________, 200___, in
_________________, Louisiana.
___________________________________
DISTRICT JUDGE
Revised October 2003
Page 4 of 4
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