Nebraska State Court Form AFFIDAVIT AND APPLICATION TO PROCEED IN FORMA PAUPERIS (Child Support or Visitation Contempt) DC 6:5(35) Rev. 05/15 Neb. Rev. Stat. �� 25-2301 to 25-2310 IN THE DISTRICT COURT OF ________________________ COUNTY, NEBRASKA (county where original action filed) ________________________________, (name of person listed as plaintiff in original action) Plaintiff, vs. ________________________________, (name of person listed as defendant in original action) Case No. CI __________________ (case number assigned by Clerk of Court) AFFIDAVIT AND APPLICATION TO PROCEED IN FORMA PAUPERIS (Child Support or Visitation Contempt) (Request to Proceed Without Payment of Fees) Defendant. STATE OF NEBRASKA ) ) ss: COUNTY OF _______________________ ) (county where signed) The undersigned, being first duly sworn on oath, deposes and says that: 1. I am the party requesting the Court for an Order to Show Cause (Child Support or Visitation Contempt), and I am of lawful age. 2. 3. I bring this action in good faith, and I am entitled to redress. I am unable to pay the cost of litigation, including the cost of service, and am unable to provide security. 4. I have a net income of only $____________________ (your net monthly income) per month, derived from ________________________________, (i.e., employment, public benefits, Social Security, etc.) and I support a household of ________ people. (number of people you support) Page 1 of 3 Affidavit and Application to Proceed In Forma Pauperis (Child Support or Visitation Contempt DC 6:5(35) Rev. 5/15 American LegalNet, Inc. www.FormsWorkFlow.com 5. My only assets or resources, over which I have control or possession, are: Cash on hand ..................................................................................................$ Bank accounts ................................................................................................$ Vehicles..........................................................................................................$ Real estate ......................................................................................................$ Securities, stocks, bonds ................................................................................$ Tools, equipment............................................................................................$ Jewelry ...........................................................................................................$ Other ..............................................................................................................$ TOTAL......................$ 6. My necessary estimated monthly expenses are: Rent or house payment...................................................................................$ Utilities (Electricity, natural gas, propane) ....................................................$ Telephone.......................................................................................................$ Automobile payment (monthly) .....................................................................$ Automobile insurance (monthly) ...................................................................$ Gasoline for vehicle .......................................................................................$ Auto upkeep and repair ..................................................................................$ Doctor, dentist, medicines..............................................................................$ Food ...............................................................................................................$ Cable TV, internet, etc. ..................................................................................$ Clothing, dry cleaning, laundry .....................................................................$ Haircuts ..........................................................................................................$ Church ............................................................................................................$ Entertainment .................................................................................................$ Personal care items ........................................................................................$ Other (Credit cards, etc.)................................................................................$ TOTAL......................$ Affidavit and Application to Proceed In Forma Pauperis (Child Support or Visitation Contempt DC 6:5(35) Rev. 5/15 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 7. Other financial circumstances of which I would like the court to be aware: 8. I believe that my living expenses wholly absorb my income, and that I have no assets which can be liquidated. WHEREFORE, pursuant to Neb.Rev.Stat. �� 25-2301 to 25-2310, I request that the Court authorize me to proceed in forma pauperis and direct ________________________ (name of county where original action filed) County, Nebraska, to pay my costs, including service fees and other expenses related to this action and waive provision of security. Date Your Signature Your Full Name Your Full Street Address/P.O. Box City/State/ZIP Code Phone E-mail Address SUBSCRIBED AND SWORN to before me this _____day of _______________, 20___. ________________________________ Notary Public Affidavit and Application to Proceed In Forma Pauperis (Child Support or Visitation Contempt DC 6:5(35) Rev. 5/15 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com