Hunt Law Firm

Lake Charles Injury & Criminal Defense Attorney

Pauper Intake Form

DISCLAIMER: Submitting this form does not create an attorney/client relationship

Your Personal Information

Full Name:

Social Security Number:

Date of Birth:

Current Physical Address:

	Apartment #

City:

	State:		Zip Code:

Phone Number:

	Work Phone Number:

Your Educational History and Employment

Are you a student?

If so, please indicate the name of the school you are attending:

Occupation:

Are you employed?

Place of Employment:

Street Address:

	Suite Number:

City:

	State:		Zip:

Employer's Phone Number:

Years Worked:

	Months Worked:

If unemployed, list the name of your last employer:

If unemployed, how long have you been unemployed:

Years Unemployed:		Months Unemployed:

Your Income

Income:

Weekly Wages:		Monthly Wages:

Monthly Deduction Federal Income Tax:
Monthly Deduction FICA:
Monthly Deduction Other:
Other Monthly Income Amount:

Is your income less than or equal to 125% of the federal poverty level?

Your Family

Marital Status:

How many children do you support who are under 18?
How many children live with you?
Do you have any other dependants?

If so, state names, ages, and relationship:

Dependant Name	Age	Relationship

Spouse's Employment

Is your spouse employed?

Place of Employment:

Street Address:

	Suite Number:

City:

	State:		Zip:

Employer's Phone Number:

Years Worked:

	Months Worked:

Income:

Weekly Wages:		Monthly Wages:

Additional Income/Support

Do you or your spouse receive any of the following income or support?

SSI Recieved Per Month:	$
TANF Recieved Per Month:	$
Child Support Recieved Per Month:	$
Disability Recieved Per Month:	$
Comp Recieved Per Month:	$
Rent Supplement Recieved Per Month:	$
Unemployment Recieved Per Month:	$
Food Stamps Recieved Per Month:	$

Your Equity

Do you own or have an interest in any of the following? (Including community property)

House	Value:	$	Balance Owed:	$
Auto	Value:	$	Balance Owed:	$
Truck	Value:	$	Balance Owed:	$
Watercraft	Value:	$	Balance Owed:	$
Livestock	Value:	$	Balance Owed:	$
Machinery	Value:	$	Balance Owed:	$
Stock	Value:	$
Bonds	Value:	$
Certificates of Deposit	Value:	$
Other Immovable Property	Value:	$	Balance Owed:	$
Bank Account	Value:	$

Bank Name:

Bank Street Address:

City:

	State:		Zip:

Your Expenses

Please list your monthly expenses:

Rent:	$	Lot Rent:	$	House Note:	$
Gas:	$	Electric:	$	Water:	$
Telephone:	$	Cable:	$	Garbage:	$
Property Taxes:	$	House Insurance:	$	Medical Insurance:	$
Medical Expenses:	$	Dental Expenses:	$	Prescriptions:	$
Life Insurance:	$	Car Note:	$	Car Insurance:	$
Transportation:	$	Food:	$	Barber/Beauty:	$
Entertainment:	$	Child Support:	$	Daycare:	$
Cleaning Supplies/Toiletries:	$	Other:	$	Garnishment:	$

Support for children other than those of this marriage:	$

Credit cards (List type of card and monthly payment)

	Credit Card Type		Monthly Payment
			$
			$

Loans (List the financial institution and the amount you pay monthly)

	Financial Institution		Monthly Payment
			$
			$

Total Monthly Expenses (Aproximate):	$

Additional Income/Expenses

Does anyone regularly help you pay your expenses?

Name of the person who helps pay expenses:

Full Name:

Their relationship to you:

Do you have any additional income or assets that are not shown above?

If so, please explain:

Legal / Fees

What arrangements have you made to pay your attorney's fee and what amount, if any
have you paid? (You are required to answer fully.)

Has you attorney explained to you that it is a crime punishable by imprisonment to intentionally give a false answer to any of the above questions?