Affidavit Or Declaration In Support Of Application To Waive Fees And Costs {36}

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Mobile Home Landlord or Tenant Affidavit/Declaration Form #36 IN THE JUSTICE COURT OF __________________________ TOWNSHIP IN AND FOR THE COUNTY OF _________________, STATE OF NEVADA Name: Address: Phone: ______________________ ______________________ ______________________ ______________________ Landlord/Plaintiff CASE NO: ________________ _____________________ _____________________ _____________________ _____________________ Tenant/Defendant DEPT. NO:________________ vs. Name: Address: Phone: AFFIDAVIT/DECLARATION IN SUPPORT OF APPLICATION TO WAIVE FEES AND COSTS I, 1. , 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 own knowledge. 2. 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. 1 of 4 ©2006 Nevada Supreme Court Revised: April 17, 2006 American LegalNet, Inc. www.FormsWorkflow.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Other 3. I wish to file with this Court but I cannot pay the costs of filing because I lack sufficient income, assets or other resources. Including myself, there are ____ adults and ____ children in my household. Their age(s) is/are ______, ______, _______, and ______. My total monthly income before taxes is: From all sources including employment, self-employment, social security, child support, alimony, State and County benefits, etc. .............................. $________________ Any other household income from another member of the household:....................................... $________________ List where you work and your job title:___________________________________ _________________________________________________________________ The following represents a list of my assets and their value: Value Automobile (year and type of car) $ Mobile Home (model, year and size), House, or Other Real Estate $ Bank Accounts (bank name; type of account) $ $ $ $ $ $ Loan Balance $ $ $ 2 of 4 $ $ $ Mobile Home Landlord or Tenant Affidavit/Declaration Form #36 ©2006 Nevada Supreme Court Revised: April 17, 2006 American LegalNet, Inc. www.FormsWorkflow.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 My total monthly expenses are: Rent or Mortgage........................................................................ $_____________ Phone, Gas, Electricity, and Other Utilities ................................. $_____________ Food ........................................................................................... $_____________ Child Care .................................................................................. $_____________ Insurance.................................................................................... $_____________ Medical ....................................................................................... $_____________ Transportation ............................................................................ $_____________ Child support and child care expenses paid to someone else.... $_____________ Other ___________________________.............................................. $_____________ ___________________________....................................... $_____________ ___________________________....................................... $_____________ TOTAL MONTHLY EXPENSES ........................................................... $_____________ 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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 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 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