CASE:  EL-_____________________
DEPT:  _____
IN THE JUSTICE/MUNICIPAL COURT OF ELKO TOWNSHIP
COUNTY OF ELKO, STATE OF NEVADA

THE STATE OF NEVADA,
	Plaintiff,
vs.
(Name)___________________________,
	Defendant.	APPLICATION FOR APPOINTMENT OF ATTORNEY	
 
My Mailing Address:   _______________________________________________________
My Telephone Number:  ____________________________________________________
My E-mail:  _______________________________________________________________
The Best Way to Contact Me:  _______________________________________________

I am hereby requesting the appointment of an attorney to represent me in the above-captioned case.

I hereby certify that I am without means of employing an attorney, and will provide all information in this Application with particularity, definiteness and certainty concerning my financial disability.

I acknowledge that pursuant to NRS 7.165 the Court may order me to pay a reimbursement for the services of the attorney appointed to represent me, and said reimbursement may be between $250.00 and $500.00, dependent upon the time and costs expended by my court-appointed attorney.

I promise that I will completely and truthfully answer any questions that the judge has about this Application.

APPLICATION

Do you now lawfully receive public assistance such as food stamps, temporary assistance for needy families, Medicaid, or disability insurance, or do you reside in public housing?

______ YES			_____ NO

How many dependents (people to whom you provide financial support) do you have?

I have _____ dependents, including myself.

ASSETS

Total Money I Have With Me Today in Court	$	
Total Money I Have in Other Places
(Include all liquid cash assets, such as bank and/or savings accounts, retirement accounts, etc.)	$	
Real Property I Own – Value Less Amount Owed
(Include personal residence, investment property and any other real property owned.)	$	
Total Value Personal Property I Own
(Including all personal property owned, such as vehicles, firearms, electronic equipment, etc.)	$	

MONTHLY INCOME

Job Income (After Taxes)	Source:	$	
Child Support   (I Receive)	Source:	$	
Alimony  (I Receive)	Source:	$	
Gifts  (I Receive)	Source:	$	
Government Benefits	Source:	$	
Other Income (Any Source)	Source:	$	
Other Income (Any Source)	Source:	$	
Other Income (Any Source)	Source:	$	

LIABILITIES (MORTGAGE, UTILITIES, AUTO LOAN, CHILD CARE, ETC.)

Child Support  (I Pay)	Total Owed:	Min Monthly Payment:	
Alimony   (I Pay)	Total Owed:	Min Monthly Payment:	
Other Debt:	Total Owed:	Min Monthly Payment:	
Other Debt:	Total Owed:	Min Monthly Payment:	
Other Debt:	Total Owed:	Min Monthly Payment:	
Other Debt:	Total Owed:	Min Monthly Payment:	
Other Debt:	Total Owed:	Min Monthly Payment:	
Other Debt:	Total Owed:	Min Monthly Payment:	
Other Debt:	Total Owed:	Min Monthly Payment:	
I make these statements under penalty of perjury.

STATE OF ………………………	}
	}ss.	………………………………………………………
COUNTY OF ……………………	}	Defendant

Signed and sworn to (or affirmed) before me this ………… day of …………, 2020 by 

______________________________________
Justice of the Peace/Municipal Court Judge