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Affidavit Or Declaration In Support Of Application To Waive Fees And Costs Form. This is a Nevada form and can be use in District Court Statewide.
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Tags: Affidavit Or Declaration In Support Of Application To Waive Fees And Costs, 36, Nevada Statewide, District Court
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IN THE JUSTICE COURT OF __________________________ TOWNSHIP
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IN AND FOR THE COUNTY OF _________________, STATE OF NEVADA
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Name:
Address:
Phone:
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______________________
______________________
______________________
______________________
Landlord/Plaintiff
vs.
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Name:
Address:
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Phone:
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CASE NO: ________________
_____________________
_____________________
_____________________
_____________________
Tenant/Defendant
DEPT. NO:________________
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AFFIDAVIT/DECLARATION IN SUPPORT OF
APPLICATION TO WAIVE FEES AND COSTS
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I,
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, 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
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own knowledge.
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2.
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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.
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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
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I wish to file with this Court but I cannot pay the costs of filing because I lack
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sufficient income, assets or other resources. Including myself, there are ____ adults and
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____ children in my household. Their age(s) is/are ______, ______, _______, and ______.
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My total monthly income before taxes is:
From all sources including
employment, self-employment,
social security, child support,
alimony, State and County benefits, etc. .............................. $________________
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Any other household income from
another member of the household:....................................... $________________
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List where you work and your job title:___________________________________
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_________________________________________________________________
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The following represents a list of my assets and their value:
Value
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Loan Balance
Automobile (year and type of car)
$
$
$
$
$
$
$
$
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$
$
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$
$
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$
$
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Mobile Home (model, year and size), House,
or Other Real Estate
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Bank Accounts (bank name; type of account)
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Other
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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
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My total monthly expenses are:
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Rent or Mortgage........................................................................ $_____________
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Phone, Gas, Electricity, and Other Utilities ................................. $_____________
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Food ........................................................................................... $_____________
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Child Care .................................................................................. $_____________
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Insurance.................................................................................... $_____________
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Medical ....................................................................................... $_____________
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Transportation ............................................................................ $_____________
Child support and child care expenses paid to someone else…. $_____________
Other
___________________________.............................................. $_____________
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___________________________………………………………… $_____________
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___________________________………………………………… $_____________
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TOTAL MONTHLY EXPENSES ........................................................... $_____________
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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
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I swear the above is true. Signature:__________________________________
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SUBSCRIBED AND SWORN to before me this ____ day of _________________,
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20____.
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NOTARY PUBLIC
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OR
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DEPUTY CLERK _____________________________
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OR
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THE FOLLOWING:
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Pursuant to NRS 53.045:
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"I declare under penalty of perjury under the law of the State of Nevada that the foregoing is
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true and correct."
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Executed on _____________, 20____
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______________________________
Signature
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______________________________
Print Name
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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