JUSTICE COURT, LAS VEGAS TOWNSHIP
Clark County, Nevada
Case No.
Department No.
APPLICATION
TO PROCEED
IN FORMA PAUPERIS
FOR SUMMARY
EVICTION CASES
Name of Landlord
VERSUS
Name of 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 d
efending 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
Medicaid assistance for public housing.
2.
Including myself, there are
adults and
children in my household.
3
.
My total household monthly income after taxes, (include income from employment,
unemployment
compensation, workers’ compensation, child support, Social Security, Spouse and/
or Domestic Partner's income, any other household money contributions, etc) 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:
FOR COURT USE ONLY
Upon consideration of the Application to Proceed in Forma Pauperis above, and good cause appearing
therefore,
____
The Application to Proceed in Forma Pauperis is GRANTED. The applicant shall be permitted to
proceed with Fees and Costs waived in this action as permitted by NRS 12.015.
____
The Application to Proceed in Forma Pauperis is DENIED for the following reasons:
____ The applicant is not indigent within the meaning of NRS 12.015.
___
_ The application was incomplete or not legible.
____________________
_______________________
Date Justice of the Peace/Clerk of the Court
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