Motion For Appointment Of Counsel Under Section 706(f) Of Civil Rights Act Of 1964

(Rev. 12/6/12) UNITED STATES DISTRICT COURT WESTERN DISTRICT OF LOUISIANA DIVISION Civil Action No. Plaintiff VS. Judge Magistrate Judge Defendant MOTION FOR APPOINTMENT OF COUNSEL UNDER SECTION 706 (f) OF THE CIVIL RIGHTS ACT OF 1964 PART 1: EFFORTS TO OBTAIN COUNSEL Declaring that the information I have given below is true and correct, I apply to the court for appointment of an attorney. A. Have you talked with any attorney about handling your claim? Yes No If "Yes," give the following information about each attorney with whom you talked: Attorney: When: How (by telephone, in person, etc.): Why was this attorney not employed to handle your claim? Attorney: When: How (by telephone, in person, etc.): Why was this attorney not employed to handle your claim? Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com (Rev. 12/6/12) Attorney: When: How (by telephone, in person, etc.): Why was this attorney not employed to handle your claim? B. Explain any other efforts you have made to contact an attorney to handle your claim: C. Give any other information which supports your application for the court to appoint counsel: D. Name and address of each attorney who has represented you in the last ten (10) years: Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com (Rev. 12/6/12) PART 2: FINANCIAL INFORMATION (DO NOT COMPLETE THIS PART IF YOU HAVE ALREADY SUPPLIED THIS INFORMATION IN THE APPLICATION TO PROCEED IN FORMA PAUPERIS.) 1. 2. Full Name Address (Street Address or P.O. Box) (City) 3. Marital Status: Single Divorced 4. Are you presently employed? Yes Married Widowed No (State) Separated (Zip Code) If the answer is "Yes," give your occupation, the name and address of your employer and the gross and net amount of your salary. (Occupation) (Gross Salary) (Net Salary) (Name and Address of Your Employer) 5. If you are not presently employed, state the date of your last employment, the name and address of your employer and your salary. (Date Last Employed) (Salary) (Name and Address of Your Last Employer) 6. If you are married and if your spouse is employed, state his/her name, occupation, employer, address of employer and salary. (Name of Spouse) (Occupation) (Salary) Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com (Rev. 12/6/12) 7. Approximately how much money have you received in the past twelve months from the following sources: as wages, salary, commissions or earned income of any kind? as workman's compensation or disability insurance? as rent payments, interest, dividends? as pensions, annuities or life insurance payments? from social security, unemployment compensation or welfare payments? as gifts or inheritance? from other sources? 8. How much money do you own or have in any checking or savings account? 9. Do you own or have any interest in any real estate, automobiles or other vehicles, boats, stocks, bonds, notes, or any other valuable property (excluding ordinary household furnishings and clothing)? Yes No If "Yes," give a description of the property and its estimated value. Page 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com (Rev. 12/6/12) 10. Is anyone dependent on you for support? Yes No If "Yes," give names, ages, relationship to you, and the amount you contribute toward their support. 11. List any debts you have and the amount owed. Creditor Amount Owed 12. List your monthly living expenses. Under penalty of perjury, I declare that the information given in this motion is true and correct. Date: (Signature) (Street Address or P.O. Box) (Witness) (City, State, Zip Code) - (Witness) (Area Code) (Telephone Number) American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 5