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Get NV Application To Proceed In Forma Pauperis - Storey County 2019

IN THE JUSTICE COURT OF VIRGINIA TOWNSHIP IN AND FOR THE COUNTY OF STOREY STATE OF NEVADA Name of Plaintiff s /Landlord Case No. Versus Name of Defendant s /Tenant s APPLICATION TO PROCEED IN FORMA PAUPERIS Applicant s Name Applicant s Street Address Applicant s City State and Zip Code Required Applicant s phone number/contact number EACH LINE ON THIS FORM MUST BE COMPLETED. IF A PARTICULAR ITEM DOES NOT APPLY WRITE 0 OR N/A. Failure to mark each box will result in the form being returned not accepted* COMES NOW the undersigned in Proper Person and requests pursuant to NRS 65. 040 and NRS 12. 015 to be permitted to proceed without paying costs or fees in this action as I am unable to prosecute or defend the action because I am unable to pay the costs of so doing 1. Including myself there are adults and children in my household. 2. My monthly income after taxes is as follows a* Monthly income from employment unemployment benefits workers compensation child support welfare social services etc* d. Other income explain TOTAL MONTHLY INCOME 3. My monthly expenses are as follows a* b. c* d. e. f* g. h. Rent/mortgage Phone gas electricity and other utilities Food Child care and/or child support paid to someone else Insurance Medical Transportation Other expenses explain TOTAL MONTHLY EXPENSES Page 1 of 2 VTJC App to Proceed IFP-022013 4. My assets are as follows Automobile year make and model b. Home mobile home or other real estate size type and year of home Bank accounts name of bank and account type You must answer each question below by marking either yes or no. Yes No b. Temporary Assistance for Needy Families d. Food Stamp Assistance Low-Income Home Energy Assistance Benefits provided pursuant to any public welfare Program administered by the Division of Health Care 7. Do you reside in public housing 8. Are you currently incarcerated in a jail or prison facility 5. Do you receive public assistance State Supplemental Insurance Medicaid The undersigned hereby requests and directs the Application to Proceed IN FORMA PAUPERIS Signature Dated Print Name Attorney for. IF A PARTICULAR ITEM DOES NOT APPLY WRITE 0 OR N/A. Failure to mark each box will result in the form being returned not accepted* COMES NOW the undersigned in Proper Person and requests pursuant to NRS 65. 040 and NRS 12. 015 to be permitted to proceed without paying costs or fees in this action as I am unable to prosecute or defend the action because I am unable to pay the costs of so doing 1. 040 and NRS 12. 015 to be permitted to proceed without paying costs or fees in this action as I am unable to prosecute or defend the action because I am unable to pay the costs of so doing 1. Including myself there are adults and children in my household. 2. My monthly income after taxes is as follows a* Monthly income from employment unemployment benefits workers compensation child support welfare social services etc* d. Including myself there are adults and children in my household. 2. My monthly income after taxes is as follows a* Monthly income from employment unemployment benefits workers compensation child support welfare social services etc* d. Other income explain TOTAL MONTHLY INCOME 3. My monthly expenses are as follows a* b. c* d. e. f* g.

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