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
Per NRS 53.045:
This _____day of _________________, 20_____.
“I declare under penalty of perjury that the foregoing is true and correct.”
OR
Executed on:__________________________________
________________________________________
(Date & Signature of Person Making Service)
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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