JUSTICE COURT, LAS VEGAS TOWNSHIP
Clark County, Nevada
IN FORMA PAUPERIS
Name of Plaintiff(s)/Landlord/Owner
Name of Defendant(s)/Tenant(s)/Unauthorized Occupant(s)
(Applicant’s Street Address)
(Applicant’s City, State, and Zip Code)
(Applicant’s Phone Number)
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:
Medicaid assistance for public housing.
Including myself, there are
children in my household.
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.
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
____ 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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