Fillable PIFP Self-Represented DISTRICT COURT CLARK COUNTY, NEVADA (Civil Law Self-Help Center)

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PIFP Self-Represented DISTRICT COURT CLARK COUNTY, NEVADA (Civil Law Self-Help Center)

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  • 70 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
© Clark County Self-Help Center Fee Waiver Order
Rev. Nov. 2015 ALL RIGHTS RESERVED
1
OIFP
Name: _________________________
Address: _______________________
City, State, Zip: __________________
Phone: _________________________
Email: _________________________
Self-Represented
DISTRICT COURT
CLARK COUNTY, NEVADA
_
_____________________________
Plaintiff,
vs.
_
_____________________________
Defendant.
CASE NO.: ____________________
DEPT: ____________________
Order to Proceed in Forma Pauperis
Upon consideration of the movant’s Application to Proceed in Forma Pauperis, and it
appearing that there is not sufficient income, property, or resources with which to maintain the
action, and good cause appearing therefore:
IT IS HEREBY ORDERED that (name) __________________________________
shall be permitted to proceed In Forma Pauperis with this action pursuant to the terms of this
Order.
IT IS FURTHER ORDERED that if the above-named party prevails in this action,
the Court shall enter an order pursuant to NRS 12.015 requiring the opposing party to pay the
Court, within five (5) days, the costs which would have been incurred by the prevailing party,
and those costs must then be paid as provided by law.
© Clark County Self-Help Center Fee Waiver Order
Rev. Nov. 2015 ALL RIGHTS RESERVED
2
IT IS FURTHER ORDERED that the above-named party shall be permitted to
commence or defend the action without costs. The Clerk of Court shall file or issue any
necessary writ, process, pleading, or paper without charge.
IT IS FURTHER ORDERED that the Sheriff or other appropriate officer within this
State shall make personal service of any necessary writ, pleading, or paper without charge.
IT IS FURTHER ORDERED that this Order shall not apply to costs for transcripts
or recordings of court proceedings. A separate application and order shall be required to waive
any such fees.
IT IS FURTHER ORDERED that this Order shall expire one year from the date the
Order is filed. The party shall be required to reapply for any further waiver after this Order
expires.
DATED this _______ day of _____________________, 20__.
___________________________________
DISTRICT COURT JUDGE
Respectfully Submitted:
(Signature) __________________________________
(Printed Name) _______________________________
In Proper Person
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PIFP Self-Represented DISTRICT COURT CLARK COUNTY, NEVADA (Civil Law Self-Help Center)

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Completed 8 January 2021

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