INTERPRETER SELECTION AFFIDAVIT Docket: _______ Page: ___________ Case Name: ________________________________________________________________ Comes now the undersigned as an authorized representative of the employer in this case and affirms as follows: 1. The interpreter identified below was selected for ______________________ interpretation in accordance with the priorities [language] for use of an interpreter as established in Neb. Ct. R. § 6703 of the Nebraska Supreme Court rules relating to court interpreters for the ______________________ held on ___________________________, 20 ____. [hearing or trial] 2. The interpreter selected for this proceeding is: Name: _________________________________________________ Address: _________________________________________________ 3. The interpreter identified above is: (select one) Certified pursuant to the Nebraska Supreme Court rules relating to court interpreters, Neb. Ct. R. § 6703(A). Registered, noncertified pursuant to the Nebraska Supreme Court rules relating to court interpreters, Neb. Ct. R. § 6703(B), who was selected by the undersigned after diligent efforts were made to obtain a certified court interpreter and none were found to be reasonably available. Nonregistered, noncertified interpreter who is otherwise competent to interpret in the courts who was selected by the undersigned after diligent efforts were made to obtain a certified or registered, noncertified court interpreter and none were found to be reasonably available. The undersigned affirms on this _____ day of ___________________________, 20 ____, that the above information is true and correct. Signature: _________________________________________________ Address: _________________________________________________ Phone Number: _________________________________________________ ) ) ss. COUNTY OF _________________________________________ ) STATE OF NEBRASKA Subscribed, affirmed, and acknowledged before me on this _____ day of ___________________________, 20 ____. _________________________________________________ Notary Public American LegalNet, Inc. www.FormsWorkFlow.com Revised 2/2/2010