Nebraska State Court Form FINANCIAL AFFIDAVIT Plaintiff vs. Defendant Case FINANCIAL AFFIDAVIT es-VEI 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: es-VEI hereby submit the following financial affidavit.es-ESI.Employer:Address: Length of employment:If unemployed, state reason, physical or otherwise, why you cannot be employed: es-VEII.Income (Monthly)Self Spouse A. Wages $ $ B.Welfare$ $ C.Unemployment$ $ D.Parents$ $ E.Other$ $ es-VEIII.Family Assets A. Cash on Hand $ F. Rentals $ B.Bank Accounts$ G.Tools$ C. Automobiles $ H. Equipment $ D.Real Estate$ I.Jewelry$ E.Securities, Stocks, Bonds$ J. Other $ es-VEIV. Marital Status: Single Married Divorced Widowed Name of Spouse: Number of children you are supporting and their ages: American LegalNet, Inc. www.FormsWorkFlow.com es-VEV.DebtsMonthly Expenses (continue on back, if needed) (continue on back, if needed) A. $ A. $ B. $ B. $ C. $ C. $ D. $ D. $ E. $ E. $ F. $ F. $ G. $ G. $ H. $ H. $ I. $ I. $ J. $ J. $ K. $ K. $ L. $ L. $ VI.Education Completed: es-VEI 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 Signature Name Bar Number and Firm Name (attorneys only) Street Address/P.O. Box City/State/ZIP Code Phone E-mail Address State of ) s.s. County of ) Subscribed and sworn to before me on this day of , 20 . My commission expires: Notary Public American LegalNet, Inc. www.FormsWorkFlow.com