Forma Pauperis Application Form - Louisiana Court (Page 3 of 4) in pdf

13. I own or have an interest in the following property:

(a) Cash: $__________________

(d) Real estate (list address, estimated fair market

value and equity of each property):

(b) Checking or savings accounts at

any financial institution:

(1) _____________________ $ ___________

(1) ____________________________ $ ___________

(2) _____________________ $ ___________

(2) ____________________________ $ ___________

(3) _____________________ $ ___________

(3) ____________________________ $ ___________

year of each) and estimated value:

(e) Other property such as jewelry, furniture, furs, art,

(1) _____________________ $ ___________

stocks, bonds, certificates of deposit, coin or stamp

(2) _____________________ $ ___________

collections, U.S. Savings Bonds, annuities, IRAs, etc.:

(3) _____________________ $ ___________

$ ___________________________

14. ☐

I have an interest in an estate or succession which may be or is opened and/or an interest in other civil

litigation. (State the name of the case, court where case is filed, and case number of all such matters):

_____________________________________________________________________________________

15. ☐

Other facts which support this application (describe unusual medicals, needs, expenses for recent family

emergencies or other unusual expenses to help the Court understand your budget. If more space is

needed, attach a separate page labeled Attachment 15):

_____________________________________________________________________________________

_______________________________________________________________________

NOTICE: You must immediately tell the Court if you become able to pay court costs or fees in advance or as they

become due during this action. You may be ordered to appear in court and answer questions about your ability to

pay court costs and fees.

__________________________________

MOVER’S SIGNATURE

STATEMENT OF ATTORNEY

I, the undersigned attorney, duly admitted to practice in the State of Louisiana, do hereby declare and affirm that I have

carefully reviewed the above and foregoing statement of my client and approve the client having submitted same.

_________________________________________

ATTORNEY’S SIGNATURE

_________________________________________

PRINT NAME

BAR NUMBER: ________________

TEL. NO.: _________________________________

AFFIDAVIT OF MOVER

STATE OF LOUISIANA

PARISH OF ________________________

BEFORE ME, the undersigned authority, personally came and appeared, ________________________________________

______________________________________________, who, after being duly sworn, deposed and said that (he) (she) is

the person who furnished the information contained in the above application; that (he) (she) has signed same; that the

information contained herein is true and correct; that this information is being furnished to the Orleans Parish Civil

District Court, First City Court and/or Second City Court for the purpose of obtaining an order to proceed in the above

captioned lawsuit pursuant to La. C.C.P. Arts. 5181 et seq., and mover is prepared to appear in Court to give any

information which may be desired in addition to the above. Mover further understands that the answers herein are

continuous and if Mover ever acquires any assets described herein Mover will make that fact known prior to trial of this

matter. Mover agrees to be further interrogated at any stage of these proceedings to inquire into Mover’s financial

condition. Mover knows it is a crime to intentionally swear to a known false answer.

SWORN TO AND SUBSCRIBED BEFORE ME,

THIS ________ DAY OF _______________________, _______

_________________________________________

MOVER’S SIGNATURE

_______________________________________________

(Mover or mover’s lawyer must also read the

NOTARY PUBLIC

Procedures section on page 4 and sign at the

PRINT NAME: ___________________________________

end of that section)

NOTARY/BAR NO.: _______________________________

Page 3 of 4

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

Forma Pauperis Application Form - Louisiana Court Page 3

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