Fillable PIFP Self-Represented DISTRICT COURT

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PIFP Self-Represented DISTRICT COURT

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  • 11 check-boxes
  • 60 other fields

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© Clark County Self-Help Center Fee Waiver Application
Rev. Nov. 2015 ALL RIGHTS RESERVED
1
PIFP
Name: _________________________
Address: _______________________
City, State, Zip: __________________
Phone: _________________________
Email: _________________________
Self-Represented
DISTRICT COURT
CLARK COUNTY, NEVADA
_
_____________________________
Plaintiff,
vs.
_
_____________________________
Defendant.
CASE NO.: ____________________
DEPT: ____________________
Application to Proceed in Forma Pauperis
Pursuant to NRS 12.015, and based upon the information contained in this Application
and Affidavit, I request permission from this Court to proceed without paying filing fees, or
other costs and fees as provided in NRS 12.015 because I lack sufficient financial ability.
I understand that if approved, the order allowing me to proceed in forma pauperis will
be valid for one year. I will be required to file a new Application to Proceed in Forma
Pauperis if I need further filing fees and court costs and fees waived after one year.
EMPLOYMENT: ( check one)
I am unemployed.
I am employed. My employer is and my job
title is .
I am self-employed. The name of my business is .
© Clark County Self-Help Center Fee Waiver Application
Rev. Nov. 2015 ALL RIGHTS RESERVED
2
Personal Income (write “0” for any income you do not have)
A Monthly Wages from Employment (before taxes) $
B Monthly Tip Income $
C Monthly Unemployment Benefits $
D
Public Benefits/Assistance received each month
□ TANF □ SSD □ SSI □ food stamps □ other: __________
$
E Social Security $
F Retirement / Pension $
G Monthly Child Support received $
H Other: _____________________________________ $
TOTAL INCOME (add lines A-H) $
Household Information
A How many adults (18 and up) live in the home (include yourself)?
B How many children (under 18) live with you?
TOTAL HOUSEHOLD SIZE (add A+B)
Household Income
List the names of the adults you live with and their estimated monthly earnings:
Name: Relationship: $
Name: Relationship: $
Name: Relationship: $
Monthly Expenses (write “0” for any expense you do not have)
A Rent / Mortgage $
B Utilities (electricity, gas, phone, other utilities) $
C Food $
D Child Care $
E Medical Expenses (including health insurance) $
F Transportation (insurance, gas, bus fare, etc.) $
G Other: _____________________ $
TOTAL EXPENSES (add lines A-G) $
0
0
0
© Clark County Self-Help Center Fee Waiver Application
Rev. Nov. 2015 ALL RIGHTS RESERVED
3
Assets (write “n/a” and “0” for any assets you do not have)
Asset What It’s Worth What you Owe
Checking Account
$ n/a
Savings Account
$ n/a
Car (year/make/model: )
$ $
House / Real Estate You Own
(address: )
$ $
Other:
$ $
CREDIT CARDS.
Do you have a credit card that you can use to charge the filing fee?
No Yes Yes, but my current balance is $___________
Declaration in
Support
of Request to
P
r
ocee
d
In Forma Pauperis
Briefly explain your current financial situation and why you are unable to pay the filing fee
.
For example, if you are unemployed explain why, for how long, and what efforts you are
making to obtain employment. If you are temporarily living with a friend or relative explain
for how long and how they help you financially.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
I declare under penalty of perjury under the law of the State of Nevada that the foregoing is
true and correct.
_______________ _______________________ _______________________
Date Printed Name Signature
/s/
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PIFP Self-Represented DISTRICT COURT

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Completed 24 November 2020

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