1 Code No. ____________________________ 2 Your Name: ____________________________ 3 Address: ____________________________ ____________________________ 4 Telephone: ____________________________ 5 In Proper Person 6 7 8 IN THE________ JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA 9 IN AND FOR THE COUNTY OF _________________ 10 ) 11 , ) 12 Plaintiff(s), ) ) 13 vs. ) 14 ) CASE NO.: ____________________________________, ) 15 Defendant(s). ) DEPT NO.: ) 16 ____________________________________ ) 17 APPLICATION TO WAIVE FEES AND COSTS 18 (Filing Fees/Service Only) 19 20 Pursuant to NRS 12.015, and based on the following Affidavit, I request permission from this Court to proceed without paying court costs or other costs and fees as provided in NRS 21 22 12.015 because I lack sufficient financial ability. AFFIDAVIT 23 STATE OF NEVADA ) 24 ) ss. COUNTY OF CLARK ) 25 26 I, , after being duly sworn, depose and state as follows: (your name) 27 1. I have read the contents of this Application to Waive Fees and Costs and am 28 competent to testify as to the contents of this Application ane contents are true of md th y own EXHIBIT Q 1 American LegalNet, Inc. www.USCourtForms.com>>>> 2 1 knowledge. 2 3 2. I amy, to pay the costs and fees of this case, unable, because of my financial povert 4 and I am unable to give security for the costs and fees in this matter. 5 3. I wish to file with this Court the pleading submitted with this Application. I cannot 6 pay the costs of filing because I lack sufficient income, assets or other resources. Including myself, 7 there are ____ adults and ____ children in my household. Their age(s) is/are ______, ______, 8 _______, and _______ . 9 My total monthly income before taxes is: 10 From all sources including employment, self-employment, 11 social security, child support, 12 alimony, State and County benefits, etc..................................... ..........$________________ 13 Any other household income from another member of the household:.......................................................$________________ 14 List where you work and 15 your job title: _______________________________________________________ ______ 16 The following represents a list of my assets and their value: 17 Automobile Value Loan Balance 18 $ $ 19 (year and type of car) 20 Mobile Home, House, or Other Real Estate 21 $ $ (size, type and/or year of account) 22 Bank Accounts 23 $ $ (name of bank and type of account) 24 Other 25 $ $ 26 $ $ 27 My total monthly expenses are: 28 Rent or Mortgage........................................................................ ....$_____________ EXHIBIT Q 2 American LegalNet, Inc. www.USCourtForms.com>>>> 3 1 Phone, Gas, Electricity, and Other Utilities...................................$_____________ 2 Food........................................................................ ........................$_____________ 3 Child Care........................................................................ ...............$_____________ 4 Insurance........................................................................ .................$_____________ 5 Medical........................................................................ ...................$_____________ 6 Transportation........................................................................ .........$_____________ 7 Child support and child care expenses paid to someone else $_____________ 8 Other 9 ___________________________..................................................$_____________ (list other expenses) 10 11 TOTAL MONTHLY EXPENSES............................................................$_____________ (total from above lines) 12 13 I request the Court hold a hearing on tApplication if the Court is inclined to his 14 deny same, so that I may testify as to my indigent status. 15 _ __________________ ___________ 16 ( Your signature) 17 STATE OF NEVADA ) ) ss 18 County of ___________________ ) 19 On this _______________________, ________ personally appeared before me, the 20 undersigned, a Notary Public in and for the County of ____________________________, State of 21 Nevada, ___________________________________________________, personally known to me or 22 proved to me to be the person whose nameubscribed to the above instrum is s ent who acknowledged 23 that she/he executed the above instrument freely and voluntarily and for the uses and purposes therein 24 mentioned. 25 ____________________________________ 26 NOTARY PUBLIC 27 28 EXHIBIT Q 3 American LegalNet, Inc. www.USCourtForms.com