TRUST ACCOUNT AFFIDAVIT STATE OF NEBRASKA County of ) ) ss. AFFIDAVIT ) , BEING FIRST DULY SWORN ON OATH, STATES AS FOLLOWS: (Print Name Here) I am an attorney duly licensed to practice law in the State of Nebraska, and I am familiar with the provisions of the Nebraska Supreme Court Rules concerning Trust Accounts, Rule 1.15 of the Nebraska Rules of Professional Conduct, and Trust Account Overdraft Notifications, requiring: 1) that all lawyers holding funds of clients or third persons must maintain a separate account for such funds (commonly known as a trust account) 2) that every lawyer maintaining a trust account must participate in the Interest On Lawyers Trust Account (IOLTA) Program unless a written Notice of Declination is submitted to the Chief Justice of the Supreme Court by February 15 of the year to which the Notice of Declination will apply 3) certain reporting and production by approved financial institutions in regard to overdrafts of trust accounts I am exempt from the provisions of these rules because I do not maintain a trust account and I handle no funds of clients or third persons and do not expect to receive funds of clients or third persons within the next twelve (12) months. I, or my firm, do maintain one or more trust accounts for the deposit of funds from clients or third persons. I will participate in the Interest On Lawyers Trust Accounts (IOLTA) Program for the accounts listed below that are specifically identified as IOLTA accounts. I certify that the following information pertaining to said accounts is true and accurate, and grant the following authorizations. BANK NAME & ADDRESS NAME ON ACCOUNT ACCOUNT NO. IOLTA (Please circle) Yes No* Yes No* Yes No* * Circling "No" requires a filing be made pursuant to Rule 3C of the Trust Accounts and Blanket Bonds Rules to effect a declination. Below: List names and addresses of all persons authorized to sign checks or make withdrawals on each account. Authorization to Financial Institutions IOLTA Participation: I hereby authorize any financial institution in which I maintain a trust account for client funds or third persons to automatically, and without further documentation, convert my trust account described above to an interest-bearing IOLTA account subject to the provisions of the Nebraska Supreme Court Rules. In summary, the financial institution is specifically authorized and directed to remit the interest earned, less customary services or charges, to the Nebraska Lawyers Trust Account Foundation. The Taxpayer Identification Number certification (IRS Form W-9 and 1099 information returns), if required, will show the Nebraska Lawyers Trust Account Foundation, PO Box 95103, Lincoln, NE 68509, Taxpayer I.D. No. 36-3357241, as the recipient of interest. Automatic Notice of Trust Account Overdrafts: I hereby consent to the release by the banking institution referenced above of information associated with the trust account(s) maintained at said banking institution for purposes of complying with the reporting and production requirements mandated by the Trust Account Overdraft Notification Rules as adopted by the Nebraska Supreme Court. All such notices must be sent to the Counsel for Discipline, 3808 Normal Blvd., Lincoln, NE 68506. Attorney or Firm Name: Address: Signature: Bar Number SUBSCRIBED AND SWORN TO before me this day of , 20 Instructions: Complete the form and return to: NSBA PO Box 81809 Lincoln, NE 68501 402-475-7091 402-475-7098 - Fax Notary Public: A firm may complete one affidavit (retyped on firm letterhead, signed by a partner) for all attorneys in the firm. It must list all the attorneys (and their Bar numbers) in the firm, or covered by the affidavit, and contain the same affirmations as this form, identifying all trust accounts, if they are IOLTA accounts, and the names and addresses of all persons authorized to sign checks or make withdrawals. Supreme Court Rules and other information can be found at www.nebar.com APPENDIX 1 American LegalNet, Inc. www.FormsWorkflow.com