JUSTICE COURT, LAS VEGAS TOWNSHIP
Clark County, Nevada
Case No.
Department No.
SMALL CLAIMS
MEMORANDUM OF COSTS
AND DISBURSEMENTS
Filed By:
[ ] Plaintiff
[ ] Counterplaintiff
Name of Plaintiff(s)/Counterdefendant
Name of Defendant(s)/Counterplaintiff
Court Filing Fee (not including e-filing or convenience fees)……………………………………… $
Demand Letter Certified Mailing Cost………………………………………………………………… $
Cost for Service to Defendant(s) or Counterdefendant(s)--Attach invoice as subsequent page $
E-Filing and Convenience Fees charged by E-Filing Vendor…………………………………… $
Additional Costs: Please explain the reason for the cost and value. Attach invoice(s) as subsequent pages.
Reason: ……………………………………………………………………………………………… $
Reason: ……………………………………………………………………………………………… $
Reason: ……………………………………………………………………………………………... $
TOTAL $
STATE OF NEVADA )
) ss.
COUNTY OF CLARK )
(Insert Name of Affiant) _, being duly sworn (or) under penalty of
perjury, states: that Affiant is the Attorney for Self-Represented and
has personal knowledge of the above costs and disbursements expended; that the items contained in the above Memorandum
are true and correct to the best of this Affiant’s knowledge and belief; and that the said disbursements have been necessarily
incurred and paid in this action.
* * * * * * * * * * * * * * * * * * * * * * *
Signature Dated
Print Name Attorney for
You MUST have this affidavit notarized (block on the left) or sign the unsworn declaration per NRS 53.045 (block on the right):
SUBSCRIBED AND SWORN to before me this
day of _, 20 _.
NOTARY PUBLIC in and for the
County of State of .
O R UNSWORN DECLARATION: Per 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):
(Typed or printed name):
(Date):
@ Civil Law Self-Help Center
Rev. 9/27/17
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