Form J - In Forma Pauperis Form - Parish Of East Baton Rouge (Page 4 of 4) in pdf

Form J - In Forma Pauperis Form - Parish Of East Baton Rouge Page 4

AFFIDAVIT OF THIRD PARTY

PARISH OF ___________________________________

STATE OF LOUISIANA

BEFORE ME, the undersigned Notary Public, duly commissioned and qualified in this state and

parish, personally appeared ___________________________________, who after being sworn, declared that

he/she knows the mover, ___________________________________, well, and that he/she knows that

because of the mover’s poverty and want of means, the mover is unable to pay the costs of court in advance or

as they accrue, nor is the mover able to furnish security therefor.

___________________________________

Third Party Signature

SWORN TO AND SUBSCRIBED before me this ____ day of ________________________, 20___, at

_________________________, Louisiana.

___________________________________

NOTARY PUBLIC

LEGAL SERVICE PROGRAM DECLARATION

I ATTEST that I am a duly authorized representative of a Legal Services Program funded by the

Legal Service Corporation or a Pro Bono Project that receives referrals from one of these Legal Service

Programs, and that ________________________________ has produced evidence that he/she receives public

assistance benefits, or that he/she has qualified to receive free legal services based on his/her income being

less than or equal to 125% of the federal poverty level and therefore is entitled to a rebuttable presumption

that he/she is entitled to the privilege of litigating without prior payment of costs.

___________________________________

Legal Services or Pro Bono Representative

ORDER

Considering the foregoing, let the mover herein prosecute or defend this litigation in accordance with

Louisiana Code of Civil Procedure articles 5181, et seq., without paying the costs in advance or as they

accrue, or furnishing security therefor.

THUS DONE AND SIGNED this ______ day of _____________________________, 20_____, at Baton

Rouge, Louisiana.

________________________________________

JUDGE, THE FAMILY COURT

THE FAMILY COURT

FORM J, p. 4 of 4

REVISED: NOV 2013

Form J - In Forma Pauperis Form - Parish Of East Baton Rouge Page 4