Nevada State Bar No.
Judicial District Court
What is your full name? (first, middle, last)
How old are you?
What is your date of birth?
What is your highest level of education?
Are you currently employed/ self-employed?
Date of Hire
Work Schedule (days)
Work Schedule(shift times)
Are you disabled?
What is your level of disability?
What agency certified you disabled?
What is the nature of your disability?
Date of Termination
Reason for Leaving
As of the pay period ending
My gross year to date pay
Number of hours worked per week
Gross Monthly Income
What is your average gross (pre-tax) monthly income/revenue from self-employment or businesses?
I (have/have not) retained an attorney for this case.
As of the date of today, the attorney has been paid a total of on my behalf.
I have a credit with my attorney in the amount
I currently owe my attorney a total
I owe my prior attorney a total
I swear or affirm under penalty of perjury that I have read and followed all instructions in completing this Financial Disclosure Form. I understand that, by my signature, I guarantee the truthfulness of the information on this Form. I also understand that if I knowingly make false statements I may be subject to punishment, including contempt of court.
I have attached a copy of my 3 most recent pay stubs to this form.
I have attached a copy of my most recent YTD income statement/P&L statement to this form, if self-employed.
I have not attached a copy of my pay stubs to this form because I am currently unemployed.
I hereby declare under the penalty of perjury of the State of Nevada that the following is true and correct:
That on (date) , service of the General Financial Disclosure Form was made to the following interested parties in the following manner:
Executed on the day of , 20 .
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600 S. Tonopah Dr, Suite 300 Las Vegas, NV 89106
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