1 2 3 4 5 6 7 IN THE JUSTICE COURT OF __________________________ TOWNSHIP 8 IN AND FOR THE COUNTY OF _________________, STATE OF NEVADA 9 10 11 Name: Address: Phone: 12 13 14 ______________________ ______________________ ______________________ ______________________ Landlord/Plaintiff vs. 15 Name: Address: 16 Phone: 17 CASE NO: ________________ _____________________ _____________________ _____________________ _____________________ Tenant/Defendant DEPT. NO:________________ 18 19 AFFIDAVIT/DECLARATION IN SUPPORT OF APPLICATION TO WAIVE FEES AND COSTS 20 21 22 23 24 I, 1. , state that: I have read the contents of this Application to Waive Fees and Costs and am competent to testify as to the contents of this Application and the contents are true of my 25 own knowledge. 26 2. 27 I am unable, because of my financial poverty, to pay the costs and fees of this case, and I am unable to give security for the costs and fees in this matter. 28 Mobile Home Landlord or Tenant Affidavit/Declaration Form #36 1 of 4 ©2006 Nevada Supreme Court Revised: April 17, 2006 American LegalNet, Inc. www.FormsWorkflow.com 3. 1 I wish to file with this Court but I cannot pay the costs of filing because I lack 2 sufficient income, assets or other resources. Including myself, there are ____ adults and 3 ____ children in my household. Their age(s) is/are ______, ______, _______, and ______. 4 5 My total monthly income before taxes is: From all sources including employment, self-employment, social security, child support, alimony, State and County benefits, etc. .............................. $________________ 6 7 8 9 Any other household income from another member of the household:....................................... $________________ 10 List where you work and your job title:___________________________________ 11 _________________________________________________________________ 12 13 14 The following represents a list of my assets and their value: Value 15 16 Loan Balance Automobile (year and type of car) $ $ $ $ $ $ $ $ 25 $ $ 26 $ $ 27 $ $ 17 18 19 Mobile Home (model, year and size), House, or Other Real Estate 20 21 Bank Accounts (bank name; type of account) 22 23 24 Other 28 Mobile Home Landlord or Tenant Affidavit/Declaration Form #36 2 of 4 ©2006 Nevada Supreme Court Revised: April 17, 2006 American LegalNet, Inc. www.FormsWorkflow.com 1 My total monthly expenses are: 2 Rent or Mortgage........................................................................ $_____________ 3 Phone, Gas, Electricity, and Other Utilities ................................. $_____________ 4 Food ........................................................................................... $_____________ 5 Child Care .................................................................................. $_____________ 6 Insurance.................................................................................... $_____________ 7 Medical ....................................................................................... $_____________ 8 9 10 Transportation ............................................................................ $_____________ Child support and child care expenses paid to someone else…. $_____________ Other ___________________________.............................................. $_____________ 11 12 ___________________________………………………………… $_____________ 13 ___________________________………………………………… $_____________ 14 TOTAL MONTHLY EXPENSES ........................................................... $_____________ 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Mobile Home Landlord or Tenant Affidavit/Declaration Form #36 3 of 4 ©2006 Nevada Supreme Court Revised: April 17, 2006 American LegalNet, Inc. www.FormsWorkflow.com 1 I swear the above is true. Signature:__________________________________ 2 3 4 SUBSCRIBED AND SWORN to before me this ____ day of _________________, 5 6 20____. 7 8 NOTARY PUBLIC 9 OR 10 DEPUTY CLERK _____________________________ 11 12 OR 13 THE FOLLOWING: 14 15 16 Pursuant to NRS 53.045: 17 "I declare under penalty of perjury under the law of the State of Nevada that the foregoing is 18 true and correct." 19 20 Executed on _____________, 20____ 21 22 23 24 ______________________________ Signature 25 26 27 ______________________________ Print Name 28 Mobile Home Landlord or Tenant Affidavit/Declaration Form #36 4 of 4 ©2006 Nevada Supreme Court Revised: April 17, 2006 American LegalNet, Inc. www.FormsWorkflow.com