Judicial District Court - In Forma Pauperis Affidavit

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_____________________________
*
_______ JUDICIAL DISTRICT COURT
VERSUS
*
DOCKET NUMBER: __________Div.___
Jefferson
_______________________________
*
_______________ PARISH, LOUISIANA
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
In Forma Pauperis Affidavit
All questions must be answered in full.
Note: Questions 2 and 3 should not be filled in if you are seeking protection from abuse.
1. Your Full Name: __________________________________________________________
Social Security Number
_________________ Date of Birth: _______________
(Optional):
Age: ____________
Sex: _________
2. Address: _________________________________________________________________
(Box Number or Street Address)
(City and State)
(Zip Code)
(See Note above)
3. Telephone Number(s):
) ________________
) _____________________
(HOME
(WORK
(See Note above)
4. Are you a Student? ____YES
___NO If yes, please indicate the name of the school you
are attending: _________________________________ Enrollment Status: ____________
5. Current Household:
Single:___ Married:___ Separated:___ Divorced:___ Widowed:___ Intimate partner:___
How many children do you support who are under 18? _________________________
How many children live with you? ________ Do you have any other dependents?_______
State the Name, Age and Relationship to you of the children and dependents:
NAME
AGE
RELATIONSHIP
6. What is your current Occupation? ________________Are you employed?
__YES ___NO
If yes, please complete the following Employer Information)
(
Name of Employer: ___________________________________________________________
Address: ___________________________________________________________________
(Street Address)
(City and State)
(Zip Code)
Telephone Number: ______________________ How long have you been employed? ____
(If you are not employed, please provide information of your last employer)
Name of last employer: _____________________________________________________
Address: ___________________________________________________________________
(Street Address)
(City and State)
(Zip Code)
How long have you been unemployed? _________________________________
What were your monthly wages? ___________________
7. Gross Income: (a) State your gross earned income from wages and how you are paid:
Weekly? ____ Bi-Weekly? ____ Monthly? ____
Amount/month $__________
(b) Apart from income or support listed in response to question 8(b) below, how much other
income do you receive on a monthly basis?
$__________
Monthly Deductions: Federal Income Tax: $_______ FICA: $_______
$ _________
(c)
(d) Other deductions: (explain) ______________________________________
TOTAL NET MONTHLY INCOME: (Add question 7 (a) + (b) less (c))
$ _________
Page 1 of 4
Revised October 2003

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