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oes It Las Applicati out the ju ges (Family Law Self Help Center)

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© Family Law Self-Help Center 1B-Application-Fee-Waiver.doc
Rev. 2014 ALL RIGHTS RESERVED
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PIFP
(Your Name) ________________________
(Address)___________________________
___________________________________
(Telephone) _________________________
(Email Address)______________________
DISTRICT COURT
CLARK COUNTY, NEVADA
_
_____________________
Plaintiff,
and
_
_____________________
Defendant.
CASE NO.: ____________________
DEPT NO.: ____________________
Application and Affidavit to Proceed in Forma Pauperis (Recording OR Transcript Fees)
Pursuant to NRS 12.015, and based upon the information contained in this
Application and Affidavit, I am the Plaintiff / Defendant and I request permission from this
Court to have reporting, recording, or transcription services performed at the expense of the
county, at the reduced rate as provided in NRS 12.015 because I lack sufficient financial
income, assets, or other resources.
I am requesting recording OR transcription services from the following
hearings ONLY (insert the dates of the hearings you want to obtain video/transcripts
from):_______________________________________________________________________
© Family Law Self-Help Center 1B-Application-Fee-Waiver.doc
Rev. 2014 ALL RIGHTS RESERVED
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Personal
I
n
co
me
A
If you are
Employed
�
write the Name of Employer & Job Title
If you are
Self-employed
�
write the Name of your Company
If you are
Unemployed
-
write “Unemployed”
B Total Monthly Income Before Taxes:
(If you are unemployed indicate how much money you receive
each month from unemployment benefits)
$
C Amount of Money Received Each Month from Public
Benefits/Assistance such as TANF, SSD, SSI, etc...:
$
Other
I
n
co
me
D
Amount of Money Received from other Sources of Income:
(Such as contributions from roommates or family members)
$
E Monthly Child Support Received $
Total Income (Add lines B-E)
Household
In
formation
A How Many Adults (over 18) Live with You?
B How Many Children (under 18) Live with You?
Total Number of People Living with you? (Add lines A&B) + Self
Monthly
Exp
enses
Write “$0.00" in the amount spent per month column for any expense you do not have.
Type of
Expense
Amount Spent per
Month
A Food $
B Child Care $
C Rent/Mortgage $
D Medical Expenses (including health insurance) $
E Transportation
(including car insurance, gas, bus fare, etc...)
$
F Other $
Total Monthly Expenses (Add lines A -F) $
© Family Law Self-Help Center 1B-Application-Fee-Waiver.doc
Rev. 2014 ALL RIGHTS RESERVED
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Assets
Each blank must be completed. If you do not have an asset listed, write “none” in the
Type/Make/Model column and “$0.00" in the Value and Loan Balance columns.
Description of
Asset
Type/
Make/Model
Value
Loan B
alance
Home/Property
$ $
Bank Account
$ $
Automobile
$ $
Other
$ $
Affidavit in
Support
of Request to
P
r
ocee
d
In Forma Pauperis
Briefly explain your current financial situation and why you are unable to pay the fees to obtain
transcripts and/or video
. For example, if you are unemployed explain why, for how long, and
what efforts you are making to obtain employment. If you are temporarily living with a friend
or relative explain for how long and how they help you financially.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Pursuant to NRS 53.045, I declare under penalty of perjury that the foregoing is true and
correct.
Executed on (date) _________________________________.
(Signature) ___________________________________
(Printed Name) __________________________________
© Family Law Self-Help Center 1B-Order-Fee-Waiver.doc
ALL RIGHTS RESERVED Rev. 2014
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OIFP
(Your Name) ________________________
(Address)___________________________
___________________________________
(Telephone) _________________________
(Email Address)______________________
In Proper Person
DISTRICT COURT
CLARK COUNTY, NEVADA
_
_____________________
Plaintiff,
v.
_
_____________________
Defendant.
CASE NO: ____________________
DEPT: ____________________
Order to Proceed in Forma Pauperis
(Recording OR Transcript Service)
Upon consideration of (print your name) ___________________________’s
Application to Proceed in Forma Pauperis, and it appearing that there is not sufficient income,
property, or resources with which to afford recording OR transcription services, and it
appearing services are necessary in Applicant’s case, and good cause appearing therefore:
IT IS HEREBY ORDERED that (Plaintiff/Defendant) ________________________
shall be permitted to have recording OR transcription services from the following
© Family Law Self-Help Center 1B-Order-Fee-Waiver.doc
ALL RIGHTS RESERVED Rev. 2014
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hearing(s) ONLY: ____________________________________________________________
performed at the expense of the county, at a reduced rate set by the county, as permitted by
NRS 12.015.
IT IS FURTHER ORDERED that if the named party prevails in this action, the
Court shall enter an order pursuant to NRS 12.015 requiring the opposing party to pay the
Court, within five (5) days, the costs which would have been incurred by the prevailing party,
and those costs must then be paid as provided by law.
DATED this _______ day of _____________________, 20__.
___________________________________
DISTRICT COURT JUDGE
Respectfully Submitted:
(Signature) __________________________________
(Printed Name) _______________________________
(Printed Address) _____________________________
____________________________________________
(Printed Telephone #) __________________________
In Proper Person
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