2. Case number:*
6. Owner's name / DBA:*
8. Address1
10. City
11. State
12. Zip
16. Agent's name:*
18. Address1
20. City
21. State
22. Zip
26. VS.
28. Name:*
30. Address1
32. City
33. State
34. Zip
38. COMES NOW, the undersigned and states as follows:
40. I am the:*

    1. Landlord
    2. Landlord's duly-appointed agent
42. The premises are located at:*
44. The tenancy commenced on:*
    The tenancy commenced on:
45. The amount of periodic rent is:*
47. Tenant's rent deposit:*
48. Security deposit:*
50. Cleaning deposit:*
52. The rent:*

    1. Is current
    2. Is delinquent
54. When did the tenant first become delinquent in payment, and how much is owed?
56. The Tenant has not complied with the conditions and covenants of the rental agreement or with the obligations of the Tenant as enumerated in Chapter 118A of the NRS as follows:
58. A written notice was served on the following date:*
    A written notice was served on the following date:
60. The tenant signed a written rental agreement:

    1. Yes
    2. No
62. I declare under penalty of perjury under the law of the State of Nevada that the foregoing is true and correct.
64. Your name:*
65. Date:*
    Date:
Leave This Blank:


67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit

* indicates a required field