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