JUDICIAL FINANCIAL INTEREST STATEMENT The Nebraska Supreme Court requires that this form be completed and filed by all Nebraska judges no later than May 1 of each year. Complete and return to: Clerk of the Supreme Court 2413 State Capitol Building Lincoln, NE 68509 This section for Supreme Court Use: Date Received:______________________________________ Filing Recorded:_____________________________________ Microfilmed:________________________________________ Filing for Calendar Year Ending December 31, ___________ I am a judge serving the: “ Supreme Court “ Court of Appeals “ District Court “ County Court “ Juvenile Court “ Workers’ Comp. Court OR “ Child Support Referee “ FT Clerk Magistrate I am a Judicial District (if applicable):_________________ ITEM 1 – Name, Address, and Telephone Number: Last Name First Name M.I. Address NE State City Zip Code ( ) Telephone Number ITEM 2 – Compensation for Extrajudicial Activities and Excess Expense Reimbursement: Date Place Nature of Activity Payor Amount of Compensation Page 1 American LegalNet, Inc. www.FormsWorkflow.com JUDICIAL FINANCIAL INTEREST STATEM ENT ITEM 3 - Real Property of the Filer in Nebraska: List all the real property in your name or in which you have a direct ownership interest. Real estate valued at less than $1,000 and your personal residence need not be reported. The description used must be sufficient to identify the location of the property. You do not need to use the legal description, although that may be used. Location of Property Nature of Property (i.e., agricultural, commercial, residential rental) - ITEM 4 - Sources of Bequests, Gifts, or Favors of a Value Greater Than $100 Received and the Circumstances of Each Gift Except Gifts from Relatives: Name of Donor Address of Donor Occupation or Nature of Business of Donor Circumstances of each bequest, gift, or favor or the occasion for which the gift or favor was given: Page 2 American LegalNet, Inc. www.FormsWorkflow.com JUDICIAL FINANCIAL INTEREST STATEMENT ITEM 5 - Other Financial Interests and Property Held During the Period of the Statement: You need report only items which have a fair market value of $1,000 or more. A. List the names and addresses of the institutions in which you had checking and savings accounts and certificates of deposit. Financial Institution Address B. List the name of the issuers of all stocks, bonds, and government securities that you own. C. Describe other property owned or held for the production of income not otherwise disclosed in this statement. Include leaseholds and other interests in real estate, promissory notes and other obligations owed to you, beneficial interests in trusts and estates, cash value life insurance, IRAs, deferred income and retirement plans. Do not include household goods, personal automobiles, and other intangible personal property unless such property was held primarily for sale or exchange. Page 3 American LegalNet, Inc. www.FormsWorkflow.com JUDICIAL FINANCIAL INTEREST STATEMENT ITEM 6 A. Creditors to Whom $1,000 or Greater Was Owed or Guaranteed by You or a Member of Your Family Residing in Your Household: Accounts payable, debts arising out of retail installment transactions or from loans made by financial institutions in the ordinary course of business, loans from a relative and land contracts that have been recorded with the county clerk or register of deeds need not be reported. Name Address B. Creditors Whose Loans of Any Amount Create Actual Conflicts of Interest. Describe the circumstances of each such loan and its amount. Name and Address Circumstances and Amount ITEM 7 - County or Other Nonstate Funding Sources Providing Education, Travel, or Other Benefits to You or on Your Behalf: Name of Funding Source Type or Purpose of Funding ITEM 8 - Signature of Judge and Date Date __________________________ Name _________________________________________ Please attach a sheet of paper if you need more space for any item. Page 4 American LegalNet, Inc. www.FormsWorkflow.com