IN THE JUSTICE COURT OF RENO TOWNSHIP COUNTY OF WASHOE, STATE OF NEVADA ________________ ________________ _____________________________________ Plaintiff/Landlord, Case No. ____________________ Dept. No.____________________ MOTION TO PROCEED IN FORMA PAUPERIS Vs. _____________________________________ Defendant/Tenant. MOTION Based on the following affidavit, (name) _________________________ requests this court for permission to file a (check one):  Lawsuit or eviction notice  Defense to lawsuit or eviction notice without paying court costs or sheriff fees and alleges that he/she has a meritorious claim or defense, yet lacks sufficient financial ability to pay the costs to proceed. AFFIDAVIT STATE OF NEVADA ) ) ss: COUNTY OF WASHOE ) I, (name) ___________________________________________________ declare under penalty of perjury that the statements of this affidavit are true and that the responses I have made to the questions regarding my ability to pay are true: 1) I am the (check one)  plaintiff  defendant  landlord  tenant. 2) I wish to file with this court a (check one)  lawsuit or eviction notice  defense to lawsuit or eviction notice. 3) I believe in good faith that I have a valid claim or meritorious defense, namely (state briefly your claim or defense and/or attach the document you wish to file if this motion is granted): ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 4) I cannot pay the costs of this action, as I lack sufficient income, assets or other resources. 5) There are ________ persons in my household, including myself. (If any household members are dependent upon you for support, state their ages and relationships to you: _________________________ ___________________________________________________________________________________________ 6) My total household monthly income is $_________________________ and is derived from the following sources: My wages $__________________ Wages of employed household members $__________________ ADC $__________________ General Assistance $__________________ Social Security $__________________ American LegalNet, Inc. www.FormsWorkflow.com Retirement Benefits Child Support Unemployment Benefits Worker’s Compensation Rental Income Other benefits or income $__________________ $__________________ $__________________ $__________________ $__________________ $__________________ 7) The following represents a complete list of my assets and their value (If you do not own the described items, write “none”. Do not include clothing and ordinary household furnishings. If you have loans on any of the items, notice the purchase price and loan balance): Purchase Loan Value Price Balance Car (describe)______________________________) Second Car (describe)________________________) Mobile home, house or other Real estate (describe)_________________________) Bank accounts (describe)_____________________) Other (describe)____________________________) 8) My total household monthly expenses are: Rent Utilities Food Child Care Insurance Medical Transportation Other (describe) TOTAL MONTHLY EXPENSES 9) $__________________ $__________________ $__________________ $__________________ $__________________ $__________________ $__________________ $__________________ $__________________ I desire to have a hearing before the Court in this matter. Dated: _______________________________________ Signature:____________________________________________ Address:_____________________________________________ Telephone:___________________________________________ Subscribed and sworn to before me This _____day of _________________, 20_____. ________________________________________ Notary Public/Deputy Clerk ORDER  Motion GRANTED. The Clerk of the Court shall allow _________________________________ to commence or defend such action without cost and to file or issue any necessary writ, process, pleading or paper without charge. This Order shall expire six months from the date below. IT IS FURTHER ORDERED that the Sheriff or any other appropriate public officer within the State make personal service of any necessary writ, process, pleading or paper without charge for _____________________________.  Motion DENIED. DATED: __________________________________ ______________________________________________ JUSTICE OF THE PEACE American LegalNet, Inc. www.FormsWorkflow.com