Nebraska State Court Form WARRANTLESS ARREST AFFIDAVIT CC 6:53 New 08/14 Document # Page 1 of 2 IN THE COUNTY COURT OF COUNTY, NEBRASKA STATE OF NEBRASKA Plaintiff vs. Defendant Case WARRANTLESS ARREST AFFIDAVIT I, , of the being duly sworn under oath, state that on .m., within at approximatelyCounty, Nebraska, I arrested the following defendant, without a warrant, based on the following charge(s) and facts: Name: Date of Birth: Address: Driveror State Identification Number: Offense(s) Statute Number(s)/Class(es) of Crime(s) 1) 2) 3) 4) Facts: American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 ( mark if additional facts attached) The actions constituting these crimes were committed in the county of arrest. This is an assault based upon a domestic dispute. This is a charge for violation of a protection order. Wherefore, I request that a determination be made that probable cause existed for a warrantless arrest and the pre-trial detention of the defendant. Signature of arresting Officer/Deputy Sheriff/Prosecuting Attorney Subscribed and sworn to before me this day of , 20 . Judge/Clerk Magistrate/Notary Public American LegalNet, Inc. www.FormsWorkFlow.com