IN THE JUSTICE COURT OF __________________________ TOWNSHIP IN AND FOR THE COUNTY OF _________________, STATE OF NEVADA Name: Address: Phone: ______________________ ______________________ ______________________ ______________________ Landlord/Plaintiff vs. Name: Address: Phone: CASE NO: ________________ _____________________ _____________________ _____________________ _____________________ Tenant/Defendant DEPT. NO:________________ TENANT’S AFFIDAVIT/DECLARATION IN SUPPORT OF MOTION FOR EXPEDITED RELIEF FOLLOWING ILLEGAL LOCKOUT OR UTILITY SHUT-OFF 1. The Landlord has started a pending legal action for summary eviction or unlawful detainer against me. 2. The parties entered into a rental agreement on or about the _____ day of _______________, 20____. 3. The street address for my rental unit is: __________________________ __________________________________________________________. _____ 4. PLEASE CHECK ONE OF THE FOLLOWING: _____ A. The rental agreement was not in writing. _____ B. The rental agreement was in writing. A copy of the rental agreement is attached. 5. The amount of rent was $____________. Apartment Tenant Affidavit/Declaration in Support of Motion for Expedited Relief Following Illegal Lockout or Utility Shut-off Form #18 1 of 5 ©2006 Nevada Supreme Court Revised: April 14, 2006 American LegalNet, Inc. www.FormsWorkflow.com _____ 6. PLEASE CHECK ONE OF THE FOLLOWING: _____ A. I pay rent weekly. _____ B. I pay rent monthly. _____ C. I pay rent as follows: _____________________________ ______________________________________________. _____ 7. PLEASE CHECK ONE OF THE FOLLOWING: _____ A. _____ B. 8. _____ 9. My rent payments are current. My rent is not current. I am $_____________ behind in rent. My next rental payment is due on the _____ day of ___________, 20____. PLEASE CHECK ONE OR BOTH OF THE FOLLOWING: _____ A. The Landlord barred me from entering/locked me out of my rental unit on or about the _________ day of ________________________, 20____. _____ B. The Landlord stopped my utilities or other essential services on or about the ____ day of _______________________, 20____. _____ 10. The landlord blocked entry, changed the locks and/or stopped the essential services as described below:____________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________. Apartment Tenant Affidavit/Declaration in Support of Motion for Expedited Relief Following Illegal Lockout or Utility Shut-off Form #18 2 of 5 ©2006 Nevada Supreme Court Revised: April 14, 2006 American LegalNet, Inc. www.FormsWorkflow.com _____ 11. PLEASE CHECK ONE OR BOTH OF THE FOLLOWING: _____ A. After I was blocked entry to/locked out of the rental unit, I tried to get back into the rental unit, but the Landlord refused to let me in. _____ B. After the Landlord stopped my utilities or other essential services, I asked the Landlord to restore the services, but the Landlord refused. _____ 12. As a result of the Landlord’s actions, I have damages as follows. In addition to the statutory damages of $1,000.00 allowed under NRS 118A.390, I am asking to be compensated for the following items of damages: DESCRIPTION AMOUNT $_______ $_______ __________________________________________ $_______ __________________________________________ $_______ __________________________________________ $_______ __________________________________________ $_______ _____ 13. __________________________________________ __________________________________________ Based upon the above, Tenant requests that this court: _____ A. Find that the Landlord has violated NRS 118A.390 and/or NRS 118A.480; _____ B. Assess actual and statutory damages against Landlord not to exceed the jurisdictional limit of the Justice Court. _____ C. Issue an immediate order restoring me to the rental unit and/or restoring the utilities or essential services at the rental unit; and _____ D. Enjoin the Landlord from violating the provisions of NRS 118A.390 and, if the circumstances so warrant, hold Landlord in contempt of court. Apartment Tenant Affidavit/Declaration in Support of Motion for Expedited Relief Following Illegal Lockout or Utility Shut-off Form #18 3 of 5 ©2006 Nevada Supreme Court Revised: April 14, 2006 American LegalNet, Inc. www.FormsWorkflow.com I swear the above is true. Signature:__________________________________ SUBSCRIBED AND SWORN to before me this ____ day of _________________, 20____. NOTARY PUBLIC OR DEPUTY CLERK _____________________________ OR THE FOLLOWING: Pursuant to NRS 53.045: "I declare under penalty of perjury under the law of the State of Nevada that the foregoing is true and correct." Executed on _____________, 20____ ______________________________ Signature ______________________________ Print Name Apartment Tenant Affidavit/Declaration in Support of Motion for Expedited Relief Following Illegal Lockout or Utility Shut-off Form #18 4 of 5 ©2006 Nevada Supreme Court Revised: April 14, 2006 American LegalNet, Inc. www.FormsWorkflow.com CERTIFICATE OF SERVICE Pursuant to NRCP 5(b) and JCRCP 5(b), I hereby certify that I am a nonparty over the age of 18 years, and that on ____________________________, 20____, I served a true and correct copy of the foregoing __________________________________________________________________, (Name of document that was served) addressed to: _______________________________________ _______________________________________ _______________________________________ _______________________________________ [ ] BY U.S. MAIL: I deposited for mailing in the United States mail, with postage fully prepaid, an envelope containing the above-identified document at _______________________________ (City and State), in the ordinary course of business. [ ] BY FACSIMILE TO: _______________________________ (FAX number). [ ] BY PERSONAL SERVICE: I personally hand delivered the above-identified document to the address/offices of the person named above. _______________________________ Signature of Server _______________________________ Print Name of Server Apartment Tenant Affidavit/Declaration in Support of Motion for Expedited Relief Following Illegal Lockout or Utility Shut-off Form #18 5 of 5 ©2006 Nevada Supreme Court Revised: April 14, 2006 American LegalNet, Inc. www.FormsWorkflow.com