JUSTICE COURT, HENDERSON TOWNSHIP CLARK COUNTY, NEVADA ) ) Tenant ) ) vs. ) ) ) ) ) Landlord. ) ____________________________________) IN THE MATTER OF TENANT'S REQUEST TO CONTINUE IN POSSESSION (ELDERLY OR DISABLED TENANTS ONLY) Case No. Dept. No. AFFIDAVIT The above named Tenant, being first duly sworn, deposes and says: (A) Please check the appropriate box below: The length of my lease agreement with Landlord is based on the following: The lease is indefinite with no specific expiration date. The lease is based on monthly rental payments. The lease is based on weekly rental payments. NOTE: If you have a weekly tenancy, you are not eligible to request any extension of time pursuant to this application. The lease is based on the following: (B) Please check the appropriate box(es) below: I am: 60 years of age or older, as shown by sufficient proof attached to this Application. Physically disabled, as shown by sufficient proof attached to this Application. Mentally disabled, as shown by sufficient proof attached to this Application. 1 American LegalNet, Inc. www.FormsWorkFlow.com (C) Please check the appropriate box(es) below: I have provided Landlord with a written request to continue in possession for an additional 30 days, and I have provided Landlord with sufficient proof of my age and/or disability, but Landlord refused to provide any extension of time. I have not provided Landlord with a written request to continue in possession for an additional 30 days, and/or I have not provided Landlord with proof of my age and/or disability. NOTE: If this box is checked, you are not eligible to request any extension of time pursuant to this application. Based on the above, I therefore request that the Court order Landlord to allow me to remain in possession for an additional 30 days. Tenant's Signature Tenant's Phone Number PLEASE COMPLETE SECTION 1 OR 2 BELOW: (1) NOTARY: Signed and Sworn to or Affirmed Before Me This day of , 20 . PLEASE STAMP BELOW: Notary Public (2) 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." Executed on (Date) (Signature) 2 American LegalNet, Inc. www.FormsWorkFlow.com