MOTION TO PROCEED IN FORMA PAUPERIS

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MOTION TO PROCEED IN FORMA PAUPERIS Powered By Docstoc
					              IN THE JUSTICE COURT OF RENO TOWNSHIP
                                     COUNTY OF WASHOE, STATE OF NEVADA
                                               ________________
                                               ________________

_____________________________________                                       Case No. ____________________
                    Plaintiff/Landlord,                                     Dept. No.____________________



Vs.                                                        MOTION TO PROCEED
                                                           IN FORMA PAUPERIS
_____________________________________
                    Defendant/Tenant.

                                                          MOTION
        Based on the following affidavit, (name) _________________________ requests this court for permission to file
a (check one):
              Lawsuit or eviction notice
              Defense to lawsuit or eviction notice

without paying court costs or sheriff fees and alleges that he/she has a meritorious claim or defense, yet lacks sufficient
financial ability to pay the costs to proceed.
                                                      AFFIDAVIT

STATE OF NEVADA  )
                 ) ss:
COUNTY OF WASHOE )

       I, (name) ___________________________________________________ declare under penalty of perjury that the
statements of this affidavit are true and that the responses I have made to the questions regarding my ability to pay are
true:
       1)       I am the (check one)  plaintiff  defendant  landlord  tenant.

        2)      I wish to file with this court a (check one)  lawsuit or eviction notice  defense to lawsuit or eviction
                notice.

        3)     I believe in good faith that I have a valid claim or meritorious defense, namely (state briefly your claim or
               defense and/or attach the document you wish to file if this motion is granted):
        ___________________________________________________________________________________________
        ___________________________________________________________________________________________
        ___________________________________________________________________________________________

        4)      I cannot pay the costs of this action, as I lack sufficient income, assets or other resources.

        5)     There are ________ persons in my household, including myself. (If any household members are
               dependent upon you for support, state their ages and relationships to you: _________________________
        ___________________________________________________________________________________________

        6)      My total household monthly income is $_________________________ and is derived from the following
                sources:
                               My wages                                                   $__________________
                               Wages of employed household members                        $__________________
                               ADC                                                        $__________________
                               General Assistance                                         $__________________
                               Social Security                                            $__________________
                                 Retirement Benefits                                             $__________________
                                 Child Support                                                   $__________________
                                 Unemployment Benefits                                           $__________________
                                 Worker’s Compensation                                           $__________________
                                 Rental Income                                                   $__________________
                                 Other benefits or income                                        $__________________

        7)      The following represents a complete list of my assets and their value (If you do not own the described
                items, write “none”. Do not include clothing and ordinary household furnishings. If you have loans on
                any of the items, notice the purchase price and loan balance):
                                                                                           Purchase       Loan
                                                                          Value            Price          Balance
                Car (describe)______________________________)
                Second Car (describe)________________________)
                Mobile home, house or other
                Real estate (describe)_________________________)
                Bank accounts (describe)_____________________)
                Other (describe)____________________________)

        8)      My total household monthly expenses are:
                               Rent                                                              $__________________
                               Utilities                                                         $__________________
                               Food                                                              $__________________
                               Child Care                                                        $__________________
                               Insurance                                                         $__________________
                               Medical                                                           $__________________
                               Transportation                                                    $__________________
                               Other (describe)                                                  $__________________
                               TOTAL MONTHLY EXPENSES                                            $__________________

        9)      I desire to have a hearing before the Court in this matter.

                Dated: _______________________________________
                                                          Signature:____________________________________________
                                                          Address:_____________________________________________
                                                          Telephone:___________________________________________
        Subscribed and sworn to before me
        This _____day of _________________, 20_____.

        ________________________________________
               Notary Public/Deputy Clerk
                                                              ORDER
                       Motion GRANTED. The Clerk of the Court shall allow _________________________________
to commence or defend such action without cost and to file or issue any necessary writ, process, pleading or paper without
charge. This Order shall expire six months from the date below.

                IT IS FURTHER ORDERED that the Sheriff or any other appropriate public officer within the State make
personal service of any necessary writ, process, pleading or paper without charge for _____________________________.

                       Motion DENIED.

                DATED: __________________________________

                                                                   ______________________________________________
                                                                                JUSTICE OF THE PEACE

				
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