Fillable Clark County, Nevada APPLICATION TO PROCEED IN FORMA (Civil Law Self-Help Center)

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Clark County, Nevada APPLICATION TO PROCEED IN FORMA (Civil Law Self-Help Center)

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JUSTICE COURT, HENDERSON TOWNSHIP
Clark County, Nevada
Case No.
Name of Plaintiff(s)/Landlord
Department No.
APPLICATION
TO PROCEED
IN FORMA PAUPERIS
VERSUS
Name of Defendant(s)/Tenant(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 pay 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 food stamp assistance Temporary Assistance for Needy Families (TANF)
Medicaid Low-Income Energy assistance Program for Child Care & Development assistance
Assistance from another public welfare program administered by the Division of Health Care
Financing and Policy Assistance for public housing.
2. Including myself, there are adults and children in my household.
3. My Monthly income after taxes, (include income from employment, unemployment compensation,
workers’ compensation, child support, and social security) is as follows:
$
Pursuant to NRS 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:
Approved Denied Notified:
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Clark County, Nevada APPLICATION TO PROCEED IN FORMA (Civil Law Self-Help Center)

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Completed 11 June 2022

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