Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Financial Affidavit Form. This is a Nebraska form and can be use in General Statewide.
Loading PDF...
Tags: Financial Affidavit, 6-1A, Nebraska Statewide, General
CASE NUMBER
STATE OF NEBRASKA
FORM NO. CC 6:1A
08/2007 Rev.
FINANCIAL AFFIDAVIT
IN THE COUNTY COURT OF
COUNTY, NEBRASKA
Plaintiff
FINANCIAL AFFIDAVIT
vs.
Defendant
I hereby swear that by reason of poverty:
I am unable to pay the docket fee, cost bond, and other costs of appeal, and I believe I am entitled to redress.
I am unable to afford counsel to represent me in this proceeding.
I am unable to pay the judgment assessed against me; I wish to apply for time in which to pay such judgment.
The nature of this action, defense or appeal is:
I hereby submit the following financial affidavit.
I.
Employer:
Address:
Length of employment:
If unemployed, state reason, physical or otherwise, why you cannot
be employed:
II.
III.
Income (Monthly)
A. Wages
B. Welfare
C. Unemployment
D. Parents
E. Other
$
$
$
$
$
Self
$
$
$
$
$
Spouse
Family Assets
A. Cash on Hand
B. Bank Accounts
C. Automobiles
D. Real Estate
E. Securities, Stocks, Bonds
$
$
$
$
$
F.
G.
H.
I.
J.
IV.
Debts
(continue on back, if needed)
A.
$
B.
$
C.
$
D.
$
VI.
$
$
$
$
$
Marital Status: Single Married Divorced Widowed
Name of Spouse:
Number of children you are supporting and their ages:
V.
Rentals
Tools
Equipment
Jewelry
Other
Education Completed:
Monthly Expenses
(continue on back, if needed)
A.
$
B.
$
C.
$
D.
$
Continued on reverse
American LegalNet, Inc.
www.FormsWorkflow.com
I swear, or affirm, under penalty of perjury, that the foregoing financial affidavit is true and hereby request the
following:
Waiver of payment of docket fee, cost bond and other costs of appeal.
Appointment of counsel to represent me in this proceeding.
Additional time in which to pay the judgment assessed against me.
DATE:
DEFENDANT:
ADDRESS:
PHONE NUMBER:
D.O.B.
SUBSCRIBED AND SWORN TO BEFORE ME:
American LegalNet, Inc.
www.FormsWorkflow.com
