Application For Appointment Of Attorney

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Code: Name: __________________________ Address: __________________________ ____________________________________ Telephone: __________________________ Email: __________________________ Self-Represented Litigant IN THE FAMILY DIVISION OF THE SECOND JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA IN AND FOR THE COUNTY OF WASHOE In the Matter of: _______________________________________ _______________________________________ _______________________________________, Minor Child(ren). _______________________________________/ APPLICATION FOR APPOINTMENT OF ATTORNEY I declare that, pursuant to NRS 12.015, I am requesting that the Court appoint an attorney to represent me in the above-entitled matter. I am the of at least one of the children listed above. PARENT -ORLEGAL GUARDIAN Case No. ___________________ Dept No. _________ I. Monthly Benefits Received: Check each box that applies to you. You may need to check more than one box. If you are not receiving any of the benefits listed, proceed to section II. I receive benefits from one or more of the following programs (please check all that apply): 25 Supplemental Security Income (SSI); 26 Food Stamps; Medicaid; Food Stamps; Temporary Assistance for Needy Families (TANF); 27 Subsidized Housing through Reno Housing Authority; 28 REV 4/2016 CG Client of Legal Services. 1 F-14 APPLICATION American LegalNet, Inc. www.FormsWorkFlow.com 1 2 II. Monthly Money Earned and Received: Check each box that applies to you and fill in the information requested. 3 You may need to check more than one box. 4 5 6 7 I am working and my hourly wage is $____________. I work ____________ hours per week. I am not paid by the hour; I receive a salary in the following amount: 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 $____________________________ per year OR $__________________________per month. I receive commissions or tips each month in the following amount: $ I receive unemployment benefits each week in the amount of: $___________ I receive veterans or social security benefits (retirement, disability, widows, dependents or survivor, TANF, WIC, or Food Stamps) each month in the following amount: $___________ I receive child support, spousal support or alimony each month in the following amount: $___________ I receive pension or annuity payments each month in the following amount: I receive other sources of income (such as rent, military basic allowance for quarters (BAQ), veterans payments, annuities, or trust payments) each month in the following amount: $___________ $____________ 24 25 26 27 I am not employed at the present time and am not receiving any kind of income or benefits. (If you have checked this box, please explain how you are meeting your basic living needs. For example, are you living with others who are helping to support you, are you in a homeless 28 REV 4/2016 CG 2 F-14 APPLICATION American LegalNet, Inc. www.FormsWorkFlow.com 1 2 3 4 5 6 7 shelter or are you meeting your needs in other ways? Please explain here): _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ If more room is needed, attach additional sheets. III. List of Assets and Their Value 8 9 10 11 Check each box that applies to you and fill in the information requested. You may need to check more than one box. Motor Vehicle(s): 12 13 14 15 16 (Print the Year, Make, and Model) 17 18 19 (Print the Year, Make, and Model) (Print the Year, Make, and Model) What is it worth? $____________ Amount owed. $____________ $____________ $____________ $____________ $____________ What is it worth? Home or Real Estate other than where you live: $____________ Amount owed. $____________ 20 21 22 23 Accounts or Other Personal Property (saving, checking, stocks, bonds, investments, retirement, jewelry, furs, furniture, etc.): $____________ $____________ 24 25 26 27 28 REV 4/2016 CG (Print the Type of Account ) $____________ (Print the Type of Account ) $____________ I have cash in the amount of: $____________ 3 F-14 APPLICATION American LegalNet, Inc. www.FormsWorkFlow.com 1 2 3 4 IV. People Who Live in Your Home: Include only your spouse, children and other people in the home who you help to support or who help to support you. When listing children please include only their 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 initials rather than their first and last names. If a person helps support you, list the amount of money they contribute each month. Name Age Relationship Gross Monthly Income (1) (2) (3) (4) (5) (6) (7) (8) $____________ $____________ $____________ $____________ $____________ $____________ $____________ $____________ V. Custody and Child Support Check each box that applies to you and fill in the information requested. You may need to check more than one box Other parent(s) to the child(ren) __________________________________________________ Current relationship to other parent(s) to the child(ren): Married Living together Divorced Separated (Parent/s name/s) Not together, but both involved in the child(ren's) lives Other parent does not have contact with you or the child(ren) Other: ____________________________________________________________________ REV 4/2016 CG 4 F-14 APPLICATION American LegalNet, Inc. www.FormsWorkFlow.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Do you have a custody agreement? YES -OR- NO YES -ORNO If yes: Is this custody agreement the result of a court order? If yes: What county was the court order entered in? ___________________________________ Do you pay child support? YES -ORNO YES -ORNO If yes: Is this child support arrangement the result of a court order? If yes: What county was the court order entered in? ___________________________________ Amount of child support owed per month $_______________________ Do you or should you receive any child support? YES -ORNO YES -ORNO If yes: Is this child support arrangement the result of a court order? If yes: What county was the court order entered in? ___________________________________ Amount owed per month $_______________________ If there is additional information you believe the court should consider, please write it here: _______________________________________________________________________________ _____________________________________