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, Case No. (case number assigned by erk of ourt) Plaintiff, AFFIDAVIT AND APPLICATIONvs. , TO PROCEED IN FORMA PAUPERIS(Request to Proceed Without Payment of Fees) STATE OF NEBRASKA ) ) ss: )COUNTY OF (county where signed) 4. I have a net income of $ per month, (your net monthly income) (i.e., employment, public benefits, Social Security, etc.)(number of people you support) AFFIDAVIT AND APPLICATIONTO PROCEED IN FORMA PAUPERIS (Request to Proceed Without Payment of Fees) The undersigned, being first duly sworn on oath, deposes and says that: 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 publication, 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 ...........................................................................................................$ 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 (..............................................................$ TOTAL .......................$ American LegalNet, Inc. www.FormsWorkFlow.com 7.Other financial circumstances of which I would like the court to be aware: 8. I believe my living expenses wholly absorb my income, and I have no assets be liquidated. WHEREFORE, pursuant to Neb.Rev.Stat. 247247 25-2301 to 25-2310, I request ourt authorize me to proceed in forma pauperis and direct me of county where action filed)County, Nebraska, to pay my costs, including fees and other expenses related to this action and waive provision of security. Date 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 American LegalNet, Inc. www.FormsWorkFlow.com