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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  • 12 check-boxes
  • 61 other fields

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© 2021 Family Law Self-Help Center Fee Waiver Application
Page 1 of 3
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
I am unable to pay the costs of prosecuting or defending this action. I request permission
to proceed without paying costs or fees pursuant to NRS 12.015 based on the following:
Public Assistance. I receive federal and/or state public assistance benefits: ( check all
that you receive)
Medicaid / Nevada Check Up
SNAP (food stamp assistance)
TANF (temporary assistance for needy families)
Low-income energy assistance
Child care subsidy / Child Care & Development Fund assistance
Public housing
SSI (supplemental security income)
Other federal and/or state public assistance: ________________________
If you checked one of the above, you do not need to fill out the rest of this form. Sign and
date page 3.
© 2021 Family Law Self-Help Center Fee Waiver Application
Page 2 of 3
Low income. My household net income is equal to or below 150% of the federal poverty
guidelines. Fill out the information below.
In my household there are adults (over 18) and children (under 18)
for a total of __________ people.
My monthly income (all numbers should be after taxes are taken out):
Employment (include tip/overtime)
$
Unemployment
$
Retirement / Pension
$
Social Security
$
Child Support
$
YOUR TOTAL
$
For each adult in the home, list their name and net monthly income (after taxes):
My total income (your total from above):
$
Adult’s name:
$
Adult’s name:
$
Adult’s name:
$
Adult’s name:
$
HOUSEHOLD TOTAL
$
My basic expenses are more than my income. Fill out the charts below.
My monthly income:
Employment (include tip/overtime)
$
Unemployment
$
Retirement / Pension
$
Social Security
$
Child Support
$
TOTAL
$
My basic monthly expenses:
Rent / Mortgage
$
Utilities (electric, gas, water, phone, other utilities)
$
Food
$
Child care
$
Medical expenses (health insurance, co-pays, out
of pocket expenses)
$
Transportation (bus fare, car, gas, insurance)
$
TOTAL
$
0
0
0
0
© 2021 Family Law Self-Help Center Fee Waiver Application
Page 3 of 3
Other Compelling Reason.
Explain
why you cannot pay the
filing fee
.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
I understand that if approved, the order allowing me to proceed in forma pauperis will
be valid for one year. I will have to file a new application to proceed in forma pauperis if I
need filing fees and court costs waived after one year.
I declare under penalty of perjury under the law of the State of Nevada that the foregoing
is true and correct.
DATED __________________________, 20___.
Submitted By: (Signature)_________________________________
Printed Name: _________________________________
/s/
© 2021 Family Law Self-Help Center Fee Waiver Order
Page 1 of 2
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, the
Court finds that the movant may proceed as an indigent litigant.
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.
© 2021 Family Law Self-Help Center Fee Waiver Order
Page 2 of 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.
___________________________________
JUDGE
Respectfully Submitted:
(Signature) __________________________________
(Printed Name) _______________________________
/s/
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PIFP Self-Represented DISTRICT COURT CLARK COUNTY, NEVADA (Civil Law Self-Help Center)

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Completed 30 June 2022

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