JUSTICE COURT, LAS VEGAS TOWNSHIP
Clark County, Nevada
Case No.
Department No.
APPLICA
TION
TO PROCEED
IN FORMA PAUPERIS
Name of Plaintiff(s)/Landlord/Owner
VERSUS
Name of Defendant(s)/Tenant(s)/Unauthorized Occupant(s)
(Applicant’s Name)
(Applicant’s Street Address)
(Applicant’s City, State, and Zip Code)
(Applicant’s Phone Number)
(Applicant’s Email)
I am unable to p
ay the costs of prosecuting or defending this action. I am requesting, pursuant to NRS
65.040 and NRS 12.015, to proceed without paying costs or fees, based on the following:
1.
I receive
Medicaid assistance for public housing.
2.
Including myself, there are
adults and
children in my household.
3
.
M
y total household monthly income after taxes, (include income from employment,
unemployment compensation, workers’ compensation, child support, Social Security, Spouse and/
or Domestic Partner's income, any other household money contributions, etc) is as follows:
$_________________.
Pursuant to N
RS 53.045, I declare under penalty of perjury under the law of the State of Nevada that the
foregoing is true and correct.
Signature:
Name:
Date:
FOR COURT USE ONLY
Order Regarding Application to Proceed in Forma Pauperis
Upon consideration of the Application to Proceed in Forma Pauperis above, and good cause appearing
therefore,
____ IT IS HEREBY ORDERED that the Application is GRANTED. The applicant shall be permitted to
proceed with Fees and Costs waived in this action as permitted by NRS 12.015.
____ IT IS HEREBY ORDERED that the application is DENIED for the following reasons:
____ The applicant is not indigent within the meaning of NRS 12.015.
___ Other: ________________________________________________________
____________________
_______________________
Date Justice of the Peace
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