1 2 3 4 5 6 IN THE JUSTICE COURT OF __________________________ TOWNSHIP 7 IN AND FOR THE COUNTY OF _________________, STATE OF NEVADA 8 9 Name: Address: 10 11 Phone: ______________________ ______________________ ______________________ ______________________ Landlord/Plaintiff 12 vs. CASE NO: ________________ 13 14 Name: Address: 15 16 Phone: _____________________ _____________________ _____________________ _____________________ Tenant/Defendant DEPT. NO:________________ 17 18 19 VERIFIED COMPLAINT FOR ILLEGAL LOCKOUT OR UTILITY SHUTOFF 20 21 22 23 24 25 The Tenant named above hereby files this Complaint against the Landlord named above and hereby alleges as follows: 1. PLEASE CHECK ONE OF THE FOLLOWING: _____ A. The Landlord has not started a pending legal action for summary eviction or a pending legal action for unlawful 26 detainer against me. (If you check A, you CAN use 27 this form.) 28 Apartment Tenant Verified Complaint for Illegal Lockout or Utility Shutoff Form #29 1 of 6 ©2006 Nevada Supreme Court Revised: April 14, 2006 American LegalNet, Inc. www.FormsWorkflow.com 1 _____ B. The Landlord has started a pending legal action for 2 summary eviction or a pending legal action for unlawful 3 detainer against me, or I have already been locked out 4 pursuant to another action. 5 CANNOT use this form. 6 Packet.) 7 2. 8 9 See Tenant Instruction The parties entered into a rental agreement on or about the _____ day of _______________, 20____. 3. 10 11 (If you check B, you The street address for my rental unit is: _______________________ ________________________________________________________ 4. PLEASE CHECK ONE OF THE FOLLOWING: 12 _____ A. The rental agreement was not in writing. 13 _____ B. The rental agreement was in writing. A copy of the rental 14 agreement is attached. 15 5. The amount of rent was $____________. 6. PLEASE CHECK ONE OF THE FOLLOWING: 16 17 _____ A. I pay rent weekly. _____ B. I pay rent monthly. _____ C. I pay rent as follows: ____________________________ 18 19 20 ____________________________________________. 21 7. PLEASE CHECK ONE OF THE FOLLOWING: 22 _____ A. My rent payments are current. _____ B. My rent is not current. I am $_____________ behind in 23 24 rent. 25 8. My next rental payment is due on the _____ day of 26 __________________, 20____. 27 28 Apartment Tenant Verified Complaint for Illegal Lockout or Utility Shutoff Form #29 2 of 6 ©2006 Nevada Supreme Court Revised: April 14, 2006 American LegalNet, Inc. www.FormsWorkflow.com 1 9. 2 PLEASE CHECK ONE OR BOTH OF THE FOLLOWING: _____ A. The Landlord barred me from entering/locked me out of 3 my rental unit on or about the ______ day of 4 ___________________________, 20____. 5 _____ B. The Landlord stopped my utilities or other essential 6 services 7 ___________________________, 20____. 8 10. on or about the _______ day of Please describe how the landlord blocked entry, changed the locks 9 and/or stopped the essential services._________________________ 10 ________________________________________________________ 11 ________________________________________________________ 12 ________________________________________________________ 13 ________________________________________________________ 14 ________________________________________________________ 15 _______________________________________________________. 16 11. 17 PLEASE CHECK ONE OR BOTH OF THE FOLLOWING: _____ A. After I was blocked entry to/locked out of the rental unit, I 18 tried to get back into the rental unit, but the Landlord 19 refused to let me in. 20 _____ B. After the Landlord stopped my utilities or other essential 21 services, I asked the Landlord to restore the services, 22 but the Landlord refused. 23 12. As a result of the Landlord’s actions, I have damages as follows. In 24 addition to the statutory damages of $1,000.00 allowed under NRS 25 118A.390, I am asking to be compensated for the following items of 26 damages: 27 28 Apartment Tenant Verified Complaint for Illegal Lockout or Utility Shutoff Form #29 3 of 6 ©2006 Nevada Supreme Court Revised: April 14, 2006 American LegalNet, Inc. www.FormsWorkflow.com 1 AMOUNT DESCRIPTION 2 $_______ ___________________________________ 3 $_______ ___________________________________ 4 $_______ ___________________________________ 5 $_______ ___________________________________ $_______ ___________________________________ $_______ ___________________________________ 6 7 13. Based upon the above, Tenant requests that this Court: 8 _____ A. Find that the Landlord has violated NRS 118A.390 9 and/or NRS 118A.480; 10 _____ B. Assess actual and statutory damages against Landlord 11 not to exceed the jurisdictional limit of the Justice Court. 12 _____ C. Issue an immediate order restoring me to the rental unit 13 and/or restoring the utilities or essential services at the 14 rental unit; and 15 _____ D. Enjoin the Landlord from violating the provisions of NRS 16 118A.390 and, if the circumstances so warrant, hold 17 Landlord in contempt of court. 18 Submitted by, 19 20 21 ___________________________ Date _____________________________ Signature of Tenant/Plaintiff 22 _____________________________ Print Name of Tenant/Plaintiff 23 24 25 26 27 28 Apartment Tenant Verified Complaint for Illegal Lockout or Utility Shutoff Form #29 4 of 6 ©2006 Nevada Supreme Court Revised: April 14, 2006 American LegalNet, Inc. www.FormsWorkflow.com 1 VERIFICATION 2 I, _________________________________, have read the foregoing Verified 3 Complaint and know that the contents are true of my own knowledge except for 4 those matters therein stated on information and belief, and as to those matters, I 5 believe them to be true. 6 7 ___________________________ Date _____________________________ Signature of Tenant/Plaintiff 8 9 _____________________________ Print Name of Tenant/Plaintiff 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Apartment Tenant Verified Complaint for Illegal Lockout or Utility Shutoff Form #29 5 of 6 ©2006 Nevada Supreme Court Revised: April 14, 2006 American LegalNet, Inc. www.FormsWorkflow.com 1 I swear the above is true. Signature:__________________________________ 2 3 SUBSCRIBED AND SWORN to before me this ____ day of _________________, 4 5 20____. 6 7 NOTARY PUBLIC 8 OR 9 DEPUTY CLERK _____________________________ 10 11 OR 12 THE FOLLOWING: 13 14 15 16 Pursuant to NRS 53.045: 17 18 "I declare under penalty of perjury under the law of the State of Nevada that the 19 foregoing is true and correct." 20 21 Executed on _____________, 20____ 22 23 ______________________________ Signature 24 25 26 ______________________________ Print Name 27 28 Apartment Tenant Verified Complaint for Illegal Lockout or Utility Shutoff Form #29 6 of 6 ©2006 Nevada Supreme Court Revised: April 14, 2006 American LegalNet, Inc. www.FormsWorkflow.com