Forma Pauperis Application Form - Louisiana Court Page 2
ADVERTISEMENT
1
2
3
4PART III:
FINANCIAL INFORMATION
9. ☐
My pay changes considerably from month to month. (If you checked this box, each number reported in
item No. 10 should be your monthly average for the past 12 months).
10. My monthly income:
(a) MY GROSS MONTHLY PAY IS: $_____________ (e) MY TOTAL MONTHLY INCOME IS: (c) plus (d):
$_____________________
(b)
My payroll deductions are:
(f) The number of dependents, including myself,
(list each deduction and amount)
supported by this money is: _______
(1) _________________ $___________
(g) My spouse’s occupation and employer is:
(2) _________________ $___________
______________________________________
(3) _________________ $___________
______________________________________
(4) _________________ $___________
______________________________________
MY TOTAL PAYROLL DEDUCTION AMOUNT
(h) MY SPOUSE’S GROSS MONTHLY INCOME IS:
IS: $____________________
$____________________
(c) MY MONTHLY TAKE-HOME PAY IS:
(a) minus (b): $_________________
(d) Other money I receive each month (Examples:
workers’ compensation, interest, dividends, rent,
spousal support, child support, Social Security,
and retirement):
(1) _________________ $___________
(2) _________________ $___________
NOTICE:
If you answered item No. 9 and/or No. 10, attach a copy of your most recent paycheck or
paystub, and, if applicable, that of your spouse.
11. ☐
I am represented in this case by a volunteer attorney (Examples: SLLS, Legal Aid, Pro Bono Project, Law
School Clinic).
12. ☐
MY MONTHLY EXPENSES ARE:
(a) Rent or house payments & maintenance
(l) Amounts deducted due to garnishments,
$ __________________
wage assignments and earnings
withholding orders: $_______________
(b) Food & Household supplies $_________
(c) Utilities & telephone: $__________
(m) Other expenses (specify):
(d) Clothing: $_________
(e) Laundry: $_________
(1) ____________________ $__________
(f) Medical expenses: $_________
(2) ____________________ $__________
(g) Insurance (life, health, accident, etc.): $ _______
(3) ____________________ $__________
(h) School & child care: $_________
(4) ____________________ $__________
(i) Child & Spousal support: $_________
(5) ____________________ $__________
(j) Transportation and/or auto expenses (insurance,
(6) ____________________ $__________
gas, repair): $____________________________
(k) Installment payments (state purpose & amount):
The TOTAL amount of other monthly
(1) _______________ $___________
expenses is $ ____________________
(2) _______________ $___________
(3) _______________ $___________
The TOTAL amount of other monthly
(n) MY TOTAL MONTHLY EXPENSES ARE :
installment payments is:
[add (a) through (m)]
$_____________________
$ ________________________
__________________________________
MOVER’S SIGNATURE
Page 2 of 4
Civil – Forma Pauperis Application (01-01-2015)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal