Nebraska State Court Form REQUIRED APPLICATION AND AFFIDAVIT FOR INTERVENTION ON BEHALF OF THE WELFARE OF THE WARD CC 16:2.21 Rev. 11/15 Neb. Rev. Stat. 24730-2602.01 Application and Affidavit for Intervention On Behalf of the Welfare of the Ward CC 16:2.21 Rev 11/15 IN THE COUNTY COURT OF COUNTY, NEBRASKA Case IN THE MATTER OF APPLICATION AND AFFIDAVIT FOR INTERVENTION ON BEHALF OF THE WELFARE OF THE WARD Ward/Protected Person/Incapacitated Person I, , state under oath That I am a person interested in the wellbeing of the ward/protected person.That the ward222s/protected/incapacitated person222s safety, health, or financial welfare is at issue, and theseissuesare not being adequately addressed by the guardian/conservator, based upon the following facts:(Attach additional pages for information or evidence)I ask the ourt to consider the welfare of the protected person and issue an ex parte order in the protected person222s best interest, such order to remain in full force and effect for no more than 10 days, or until a hearing can be held on this matter. I understand that any interested person that submits an affidavit under this section in bad faith, or submits an affidavit that the court determines lacks a factual basis, shall be ordered to pay the opposing party reasonable attorney222s fees and costs. 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 ) ) ss. County of ) The foregoing instrument was acknowledged before me by , this Name day of , . Day Month Year Notary Public (Signature of Person Taking Acknowledgment) (Serial Number, if any) (Title or Rank) My commission expires: American LegalNet, Inc. www.FormsWorkFlow.com