Forma Pauperis Application Form - Louisiana Court printable pdf download

CIVIL DISTRICT COURT FOR THE PARISH OF ORLEANS

FIRST CITY COURT FOR THE PARISH OF ORLEANS

SECOND CITY COURT FOR THE PARISH OF ORLEANS

STATE OF LOUISIANA

CASE NO.: __________________

SECTION _________

DIVISION ____________

____________________________________________________________

versus

____________________________________________________________

______________

Date this form is completed:

FORMA PAUPERIS APPLICATION

NOTICE

The granting of this application only suspends payment of fees and costs as they become due. All costs and fees are due

immediately upon the conclusion of the case. Failure to pay fees and costs may result in collection proceedings.

If more than one person is seeking pauper status, each person must complete a separate Forma Pauperis Application.

ALL QUESTIONS MUST BE ANSWERED IN FULL.

NOTE: Question 2 should not be completed if you are seeking protection from abuse.

I request a court order so that I do not have to pay court costs and fees in advance or as they accrue.

PART I:

1. My name is: __________________________________________________________________________________

First

Middle

Last

2. My address and telephone number is:

Street Address: __________________________________________

Apt. No.

_________________

Mailing Address: _____________________________________________________________________________

City, State, Zip Code:

______________________________________________________________________

Telephone number:

___________________________________

3. My date of birth is:

___________________________________

☐ married

☐ single

☐ widowed

4. My marital status is: (check one)

☐ separated

☐ divorced

☐ living with another who shares expenses

5. My occupation, employer and employer’s address is (if more than one, list all):

____________________________________________________________________________________________

PART II:

☐ I am not able to pay any of the court costs or fees in advance or as they become due.

7. I am receiving financial assistance under one or more of the following programs:

(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)

(d) ☐ City or Parish Relief, General Relief or General Assistance

8. (a)

If you checked a box in item No. 7, you must attach documents verifying receipt of the benefit(s)

checked.

(b)

If you checked a box in item No. 7, sign on the line below; only complete the two affidavits on pages 3

and 4; and, sign at the bottom of page 4.

_________________________________________

MOVER’S SIGNATURE

Page 1 of 4

Civil – Forma Pauperis Application (01-01-2015)

Forma Pauperis Application Form - Louisiana Court

Related Articles

Related forms

Related Categories