Form J - In Forma Pauperis Form - Parish Of East Baton Rouge Page 2
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49. Income
a. What is your monthly gross income?
______________
b. How much other income do you receive per month?
______________
c. How much is your monthly federal income tax?
______________
d. How much is your monthly FICA?
______________
e. How much are your other monthly deductions?
______________
(Add line a and line b, then subtract line c, line d, and line e)
TOTAL NET MONTHLY INCOME
______________
Please attach proof of income to this form. You may provide copies of your most recent paycheck, the prior
year’s tax return with all attachments, or W2 forms and 1099 forms if no tax return was filed.
10. Is your spouse employed? ______ What is his/her occupation? _______________________________
What is his/her monthly gross income? ______________
11. Please state the monthly amount of income that you or your spouse receive from these sources:
Worker’s Comp: _____________
Food Stamps: ______________
Kinship Care: ______________
SSI: _______________________
TANF: ___________________
Other: _____________________
Unemployment: _____________
Child Support: _____________
Disability: _________________
Spousal Support: ___________
12. Do you own or have an interest in any of the following (including community property)?
Type
Value
Balance owed
House
______________
______________
Automobile
______________
______________
Watercraft
______________
______________
Livestock
______________
______________
Machinery
______________
______________
Stock
______________
Bonds
______________
Certificate of Deposit
______________
Other Immoveable Property: ______________ Equity: ______________ Debt: ______________
Bank Account: Value ______________ Name and location of bank: _____________________________
13. Please list your monthly expenses:
Rent: _____________________
Telephone: ________________
Car Note: _________________
Lot Rent: __________________
Cell Phone: ________________
Car Insurance: _____________
House Note: _______________
Medical Insurance: __________
Transportation: _____________
Home Insurance: ___________
Medical Expenses: __________
Food: _____________________
Property Tax: ______________
Dental Expenses: ___________
Barber/Beauty: _____________
Gas: ______________________
Prescriptions: ______________
Entertainment: _____________
Electricity: _________________
Life Insurance: _____________
Grooming Supplies: _________
Cable: _____________________
Daycare: __________________
Other: _____________________
Water: ____________________
Child Support: _____________
Other: _____________________
Garbage: __________________
Garnishment: ______________
Other: _____________________
TOTAL MONTHLY EXPENSES
______________
THE FAMILY COURT
FORM J, p. 2 of 4
REVISED: NOV 2013
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