Application To Proceed In Forma Pauperis Relating To Page 2
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5CONFIDENTIAL
AFFIDAVIT
STATE OF NEVADA
)
)
ss.
COUNTY OF CLARK
)
I, _______________________________________, after being duly sworn, depose and
(your name)
state as follows:
I wish to file with this Court the concurrently submitted Affidavit. I cannot pay the costs
of this action because I lack sufficient income, assets, or other resources.
Including myself, there are __________ adults and ____________ children in my
household.
My total monthly income is: (please enter information below)
Monthly Income earned by
household from work.
$__________________________
Monthly Income from ADC,
Welfare, Clark County Social Services,
Unemployment Benefits, Worker=s
Compensation, Child Support (that you
receive) or Social Security
$___________________________
Other Income:
__________________________________
$___________________________
(Type of Income)
__________________________________
$____________________________
(Type of Income)
My total household monthly income is..................................$____________________________
(Total from above lines)
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