Nebraska > Statewide > General > Miscellaneous
Financial Affidavit 6-1A - Nebraska
| Financial Affidavit Form. This is a Nebraska form and can be used in Miscellaneous General Statewide . |
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STATE OF NEBRASKA CASE NUMBER FORM NO. 6:1A Rev. 10/99 29-1804 FINANCIAL AFFIDAVIT IN THE ________________________ COURT OF ________________________ COUNTY, NEBRASKA __________________________________ Plaintiff vs. FINANCIAL AFFIDAVIT __________________________________ Defendant I hereby swear that by reason of poverty: I am unable to pay the docket fee, cost bond, and other costs of appeal, and I believe I am entitled to redress. I am unable to afford counsel to represent me in this proceeding. I am unable to pay the judgment assessed against me, I wish to apply for time in which to pay such judgment. The nature of this action, defense or appeal is:_____________________________________________ I hereby submit the following financial affidavit. I. Employer:________________________ Address:__________________________________________ Length of employment:_____________ If unemployed, state reason, physical or otherwise why you cannot be employed:_________________________________________________________________ __________________________________________________________________________________ II. Income (Monthly) Self Spouse A. Wages $_______________ $_________________ B. Welfare $_______________ $_________________ C. Unemployment $_______________ $_________________ D. Parents $_______________ $_________________ E. Other $_______________ $_________________ III. Family Assets A. Cash on Hand $____________ F. Rentals $____________ B. Bank Accounts $____________ G. Tools $____________ C. Automobiles $____________ H. Equipment $____________ D. Real Estate $____________ I. Jewelry $____________ E. Securities, $____________ J. Other $____________ Stocks, Bonds IV. Marital Status: Single Married Divorced Widowed Name of Spouse:___________________________________________ Number of children you are supporting and their ages:_________________________________ V. Debts Monthly Expenses A.______________$______________ A._________________$_______________ B.______________$______________ B._________________$_______________ C.______________$______________ C._________________$_______________ D.______________$______________ D._________________$_______________ VI. Education Completed:__________________________________________________________ I swear, or affirm, under penalty of perjury, that the foregoing financial affidavit is true and hereby request the following: waiver of payment of docket fee, cost bond and other costs of appeal. appointment of counsel to represent me in this proceeding. additional time in which to pay the judgment assessed against me. DATE: DEFENDANT: ADDRESS: PHONE #: D: .O. B. SUBSCRIBED AND SWORN TO BEFORE ME:
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