251 Civil Law Self-Help Center Rev. 5/3/17 JUSTICE COURT, LAS VEGAS TOWNSHIP Clark County, Nevada Case No. Department No. APPLICATION TO PROCEED IN FORMA PAUPERIS Name of Plaintiff(s)/Landlord VERSUS Name of Defendant(s)/Tenant(s) (Applicant222s Name) (Applicant222s Street Address) (Applicant222s City, State, and Zip Code) (Applicant222s Phone Number) (Applicant222s Email) I am unable to pay the costs of prosecuting or defending 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 food stamp assistance Temporary Assistance for Needy Families (TANF) Medicaid Low-Income Energy assistance Program for Child Care & Development assistance assistance from another public welfare program administered by the Division of Health Care Financing and Policy assistance for public housing. If you checked any of the boxes in Question 1, skip Questions 2 & 3, and proceed to the signature box. 2. Including myself, there are adults and children in my household. 3. My monthly income after taxes, (include income from employment, unemployment compensation, workers222 compensation, child support, and Social Security) 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: American LegalNet, Inc. www.FormsWorkFlow.com