District Court - Financial Statement - District_Court_Financial

Case #:

Applicant

First Name

Middle Name

Last Name

Alias/Maiden Name(s)

Date of Birth

Phone

Street Address

Address Line 2

City

State

Zip

Country

General Delivery

Marital Status

Single Married Separated Widowed Divorced

Number of dependent minor children who reside with you that you support

Number of dependent minor children for which you pay child support

Are you current in your child support payments?

Yes No na

Current Financial Status

1. EMPLOYMENT

Employment Type

Full Time Part Time Seasonal Unemployed

2. INCOME /PER MONTH

Salary/Wages (Take Home Pay)

Spouse/Registered Domestic Partner’s income

Social Security Retirement Benefits

Other Retirement Received

Pension Received

Unemployment / Worker's Compensation

Alimony or Maintenance Received

Child Support Received

Other Source of Income

3. AVAILABLE MONEY

Cash On Hand

Checking Account(s)

Savings Account(s)

Stocks, Bonds, Trusts, CDs, Other

4. ASSETS

Value of Real Estate (home, land, bldg)

Cash Value Minus Amount Owed

Value of Vehicle(s)

Cash Value Minus Amount Owed

Vehicle Make

Vehicle Model

Vehicle Year

Monthly Expenses

All fields are required. Please enter 0 if you do not have an expense for a field

1. HOUSING COSTS

Monthly Rent or Mortgage

Utilities

(Electricity, Heat, etc.)

2. OTHER

Food

Transportation

Child/Health Care

Child Support Paid

Loan Payments

(not including vehicle, home, land, bldg)

Legal Financial Obligations

Other

Financial Statement

Clark County District Court

This form is NOT for Superior Court cases

All fields require an entry, put na if you have no response for that field