Fillable AAFW COUNTY, NEVADA CLARK Plaintiff, (Civil Law Self-Help Center)

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AAFW COUNTY, NEVADA CLARK Plaintiff, (Civil Law Self-Help Center)

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© 2021 Civil Law Self-Help Center Fee Waiver Application
Page 1 of 2
AAFW
Name: _________________________
Address: _______________________
City, State, Zip: __________________
Phone: _________________________
Email: _________________________
JUSTICE COURT, ________________TOWNSHIP
CLARK
COUNTY, NEVADA
________________________________
Plaintiff,
vs.
________________________________
Defendant.
CASE NO.: ____________________
DEPT: ____________________
Application to Proceed in Forma Pauperis
I am unable to pay the costs of prosecuting or defending this action. I request permission to
proceed without paying costs or fees pursuant to NRS 12.015 based on the following:
1. Public Assistance includes Medicaid, Nevada Check Up, SNAP (food stamp assistance), TANF,
Low-income energy assistance, Child Care & Development Fund assistance. Please indicate
whether or not you receive one or more of the above listed benefits.
Yes I receive one or more of the above listed benefits.
No I do not receive any of the above listed benefits
2. Household Members: In my household there are adults (over 18) and
children (under 18) for a total of __________ people.
3. Income includes employment (include tips/overtime), unemployment, retirement, pension, social
security, child support. Please list all income for household member: (all numbers should be
after taxes are taken out):
For each adult in the home, list net monthly income (after taxes):
My total income
$
Household Adult #1 total income
$
Household Adult #2 total income
$
Household Adult #3 total income
$
Household Adult #4 total income
$
Household Adult #5 total income
$
HOUSEHOLD TOTAL
$
© 2021 Civil Law Self-Help Center Fee Waiver Application
Page 2 of 2
4. My basic monthly expense include: Fill out the chart below.
Rent / Mortgage
$
Utilities (electric, gas, water, phone, other utilities)
$
Food
$
Child care
$
Medical expenses (health insurance, co-pays, out of pocket expenses)
$
Transportation (bus fare, car, gas, insurance)
$
Other:
$
TOTAL
$
5. Other Compelling Reason.
Explain
why you cannot pay the
filing fee
.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
I declare under penalty of perjury under the law of the State of Nevada that the foregoing is true
and correct.
DATED (month) __________________________ (day) _____, 20___.
Submitted By: (Signature)_________________________________
Printed Name: _________________________________
______________________________________________________________________________
FOR COURT USE ONLY
Upon consideration of the movant’s Application to Proceed in Forma Pauperis, and good cause
appearing therefore,
The Application to Proceed in Forma Pauperis is GRANTED. The applicant shall be
permitted to proceed with fees and costs waived in this action as permitted by NRS 12.015.
The Application to Proceed in Forma Pauperis is DENIED for the following reasons:
The applicant is not indigent within the meaning of NRS 12.015
The application was incomplete or not legible.
______________________ __________________________________
Date Justice of the Peace/Clerk of Court
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AAFW COUNTY, NEVADA CLARK Plaintiff, (Civil Law Self-Help Center)

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Completed 22 June 2022

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