Free Application to Proceed in Forma Pauperis - Nevada

JUSTICE COURT, LAS VEGAS TOWNSHIP

CONFIDENTIAL
_______________________________ (your name) _______________________________ (your street address) _______________________________ (your city, state, and zip code) _______________________________ (your phone number) IN PROPER PERSON JUSTICE COURT, LAS VEGAS TOWNSHIP CLARK COUNTY, NEVADA ____________________________ ) ____________________________ ) Plaintiff ) ) vs. ) ) ) ____________________________ ) ____________________________ ) Defendant. ) ) ______________________________) Case No. Dept. No. ________________________ ________________________

APPLICATION TO PROCEED IN FORMA PAUPERIS RELATING TO________________ _____________________________

Pursuant to NRS 65.040 and NRS 12.015, and based on the following Affidavit, I request permission from this Court to proceed without paying court costs or other costs and fees as provided in NRS 12.015 because I lack sufficient financial ability.

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CONFIDENTIAL
AFFIDAVIT STATE OF NEVADA COUNTY OF CLARK ) ) ) ss.

I, _______________________________________, after being duly sworn, depose and (your name) state as follows: I wish to file with this Court the concurrently submitted Affidavit. I cannot pay the costs of this action because I lack sufficient income, assets, or other resources. Including myself, there are __________ adults and ____________ children in my household. My total monthly income is: (please enter information below) Monthly Income earned by household from work. Monthly Income from ADC, Welfare, Clark County Social Services, Unemployment Benefits, Worker=s Compensation, Child Support (that you receive) or Social Security Other Income: __________________________________ (Type of Income) __________________________________ (Type of Income) $___________________________ $____________________________ $__________________________

$___________________________

My total household monthly income is..................................$____________________________ (Total from above lines)

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CONFIDENTIAL
The following represents a list of my assets and their value. Value Car Mobile Home, House, or Other Real Estate ____________________ (Year and type of car) $__________ Loan Balance $__________

____________________ (Size, type, and/or year of home) _____________________ (Name of bank and type of account) _____________________ _____________________ _____________________

$__________

$__________

Bank Accounts

$__________

$__________

Other

$__________ $__________ $__________

$__________ $__________ $__________

My total monthly expenses are: Rent Phone, Gas, Electricity, and Other Utilities Food Child Care Insurance Medical Transportation Other

$_____________________ $_____________________ $_____________________ $_____________________ $_____________________ $_____________________ $_____________________ $_____________________ ______________________ ______________________ (List other expenses)

TOTAL MONTHLY EXPENSES............................$______________________ (Total from above lines) ___________________________________ AFFIANT (your signature)

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THIS FORM MUST BE NOTARIZED OR ACCOMPANIED BY THE APPROPRIATE UNSWORN DECLARATION SUBSCRIBED and SWORN to before me this ___ day of _____________, 2000. (A) If executed in Nevada, please complete the following: AI declare under penalty of perjury that the foregoing is true and correct.@ ____________________________________ Notary Public Executed on __________ (Date) __________________________ (Signature) (B) If executed outside of Nevada, please complete the following: AI declare under penalty of perjury under the law of the State of Nevada that the foregoing is true and correct.@ Executed on ___________ (Date) ____________________________ (Signature)

ORDER OF THE COURT

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The Application is hereby denied.

The Application is hereby granted. The Clerk of the Court shall allow Affiant to appear in this action without paying costs, charges, or fees, and the Clerk shall file or issue any necessary writ, process, pleading, or paper without charge. IT IS FURTHER ORDERED that the Constable or Sheriff or any other appropriate public officer within the State shall make personal service of any necessary writ, process, pleading, or paper without charge. IT IS FURTHER ORDERED that if Affiant=s financial condition improves during the pendency of this action such that costs, charges, and fees can be paid from that point forward, Affiant shall immediately inform the Court as to that fact.

______________________ Justice of the Peace

_________________________ Justice of the Peace

__________ Date

___________ Date

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