EMANCIPATION CHECKLIST A. ______Yes ______ No I am at least 16 years of age. B. ______ Yes ______ No I am younger than the age of 18 years. C. ______ Yes ______ No I am currently attending regular high school, am studying for my GED or I have been excused from attending high school pursuant to Nevada Law and have proof of my status. D. ______ Yes ______ No I am managing my own financial affairs and have been for at least 6 months and can provide a budget and receipts to show how I manage my finances. E. ______ Yes ______ No My parents or my legal guardian(s) have consented to allow me to live apart from them. F. ______ Yes ______ No I am presently and willingly living apart from my parent(s) or legal guardian(s). G. ______ Yes ______ No I do not have any income from criminal activities (“yes” means you do not , and “no” means you do) H. ______ Yes ______No One hundred percent of my support is provided from funds I derive from employment. In other words, I am completely financially self-sufficient and depend upon no one else for contribution to my support. If either question A or B is answered “No”, judicial emancipation is not possible in Nevada. If A or B is answered “yes”, but one or more of the remaining questions are answered “no”, then you should seek the assistance of a private attorney. Ct. App. 3/00; Revised 7/05 1 American LegalNet, Inc. www.FormsWorkflow.com EMANCIPATION INFORMATION WORKSHEET Name:___________________________________________________________________________ Last First Middle Age:______________________Date of Birth:______________________________________ I have lived in Washoe County since (date) _____________________________________________ My parent’s or legal guardian’s address is:______________________________________________ ________________________________________________________________________________ I live apart from my parents and/or legal guardian(s) and my address is: _______________________ _________________________________________________________________________________ I go to _____________________________________________school and am in grade ___________ and will graduate on ________________________________________________________________ or I am studying for my GED at _________________________________________________________ and expect to take my exam on _______________________________________________________ I am employed at __________________________________________________________________ and have been employed there since ___________________________________________________ I earn $_______________ an hour and my gross (before deductions) income is $________________ per month. My take-home pay is $_________________________ per month. My transportation to and from work is: ________________________________________________________________ I have the following expenses every month: Groceries: $__________________________________ Rent: $____________________ Utilities:(electricity, gas, phone)_________________________ Transportation: Car payment: $_______________________Car Insurance:$____________________ Gas $__________ Maintenance: $________ Other transportation costs (bus, taxi, etc.):$ _________ Clothing:$___________________ Incidentals (haircuts,etc.) $______________________________ Ct. App. 3/00; Revised 7/05 2 American LegalNet, Inc. www.FormsWorkflow.com