Name :

Address :

Telephone :

Email Address :

Self-Represented

In the Municipal Court of Mesquite

Clark County, Nevada

STATE OF NEVADA

Plantiff,

Citation Holder,

Case No.

Application In Forma Pauperis Civil Traffic Infraction

I am unable to pay the costs of prosecuting or defending this action. I request permission to proceed
without paying costs or fees pursuant to NRS 12.015 based on the following:

1. Public Assistance includes Medicaid, Nevada Check Up, SNAP (food stamp assistance), TANF, Low-
income energy assistance, Child Care & Development fund assistance. Please indicate whether or not

you receive on or more of the above listed benefits.

Please select one :

Yes, I received one or more of the above listed ( Specify below )

No, I do not receive any of the above listed benefits

Specify :

2. Household Members : Please select number of adults (over 18) and children (under 18)

Number of adults : Value is not selected

Number of children : Value is not selected

3: Income includes employment (include tips/overtime), unemployment, retirement, pension, social
security, child support. Please list all income for household members (all amounts listed should be after
taxes are taken out.):

Household Income

My Total Income :

Household Adult #1 Total Income

Household Adult #2 Total Income

Household Adult #3 Total Income

Household Adult #4 Total Income

Household Adult #5 Total Income

Total household income :

4. My basic monthly expense include: Fill out the chart below

Rent / Mortgage

Utilities (electricity, gas, phone, other utilities)

Food

Child Care

Medical Expenses (including health insurance)

Transportation (insurance, gas, bus fare, etc.)

Other

Total Expenses

5. Other Compelling Reason

Explain why you cannot pay the filing fee.

I declare under penalty of perjury under the law of the State of Nevada that the foregoing is true and correct.

Signature :

Date Signed :

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In Forma Pauperis Civil Traffic Infraction