Nevada > County > Clark > Justice Court > Las Vegas Township > Small Claims
Application To Proceed In Forma Pauperis - Nevada
| Application To Proceed In Forma Pauperis Form. This is a Nevada form and can be used in Small Claims Las Vegas Township Justice Court Clark County . |
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JUSTICE COURT, LAS VEGAS TOWNSHIP Clark County, Nevada Name of Plaintiff(s)/Landlord Case No. Department No. VERSUS Name of Defendant(s)/Tenant(s) APPLICATION TO PROCEED IN FORMA PAUPERIS (Applicant's Name) (Applicant's Street Address) (Applicant's City, State, and Zip Code) (Required - Applicant's Phone Number & E-Mail Address) EACH LINE ON THIS FORM MUST BE COMPLETED. IF A PARTICULAR ITEM DOES NOT APPLY, WRITE "0" OR "N/A." Failure to mark each box will result in the form being returned "not accepted" COMES NOW, the undersigned, in Proper Person, and requests pursuant to NRS 65.040 and NRS 12.015 to be permitted to proceed without paying costs or fees in this action as I am unable to prosecute or defend the action because I am unable to pay the costs of so doing; 1. 2. Including myself, there are adults and children in my household. My monthly income, after taxes, is as follows: a. Monthly Income from Employment: b. Monthly income from social security, unemployment benefits, worker's compensation, child support, Welfare, Clark County Social Services, etc . . . c. Monthly income from any other household member: d. Other Income (explain): $ $ $ $ TOTAL MONTHLY INCOME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 3. My monthly expenses are as follows: a. Rent/Mortgage: b. Phone, gas, electricity and other utilities: c. Food: d. Child Care and/or Child Support paid to someone else: e. Insurance: f. Medical: g. Transportation h. Other Expenses (explain): $ $ $ $ $ $ $ $ TOTAL MONTHLY EXPENSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Original-File LVJCVL- 9 Form Revised 1/12 Copy-Applicant 1 American LegalNet, Inc. www.FormsWorkFlow.com 4. My assets are as follows: a. Automobile(s): (Year, make, and model) $ (Market price less loan balance) b. Home, mobile home or other real estate: (Size, type and year of home) $ (Market price less loan balance) c. Bank Account(s): (Name of bank and account type) $ (Account balance) d. Other Assets (explain) $ (Value) You must answer each question below by marking either "YES" or "NO": Failure to mark each box will result in the form being returned "not accepted" 5. Do you receive "public assistance"? a. b. c. d. e. f. g. [ ] Yes [ ] No [ ] No [ ] No [ ] No [ ] No [ ] No [ ] No The term public assistance does not include the Children's Health Insurance Program Do you receive any of the following: State Supplemental Assistance;[ ] Yes Temporary Assistance for Needy Families; Medicaid; Food Stamp Assistance Low-Income Home Energy Assistance; The Program for Child Care and Development; Benefits provided pursuant to any other public welfare program administered by the Division of Health Care Financing and Policy [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] No [ ] No [ ] No [ ] No 6. 7. 8. Do you reside in "public housing"? Are you currently incarcerated in a jail or prison facility? Are you currently housed in a public or private mental health facility? *********************** The undersigned hereby requests and directs the Entry of Default: (Signature) ________________________________________________________________________________________________ (Dated): ____________________________________ Print Name: _________________________________________________________________________________ Attorney for: _______________________________________________ Original-File LVJCVL- 9 Form Revised 4/12 Copy-Applicant 2 American LegalNet, Inc. www.FormsWorkFlow.com
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