IN THE NEBRASKA WORKERS' COMPENSATION COURT ) ) ) ) ) ) ) ) ) ) ) ) ) ) ss: ) Docket: ___________________________ Page: ____________________________ _____________________________________________________________________________________ _____________________________________________________________________________________, [employee name] Plaintiff, vs. _____________________________________________________________________________________ AFFIDAVIT AND APPLICATION TO PROCEED WITHOUT PAYMENT OF COSTS _____________________________________________________________________________________, [name of employer or name of employer and insurance company] Defendant(s). STATE OF NEBRASKA COUNTY OF ___________________________________________________________________________ [county where signed] The undersigned, being first duly sworn on oath, deposes and says that: 1. 2. 3. I am a claimant for workers' compensation. The trial judge in my case issued a decision in my case, and I now wish to appeal that decision to the Nebraska Court of Appeals. I am without means to pay for the costs of the appeal. I am presently (check only one): employed and earning approximately $________________________ per month. I am employed by ______________________________. My employer's address is [salary] [name of employer] __________________________________________________________________________________________________________________. [street address, city, state, postal code] unemployed. My last employment date was ______________________________. In that employment, I earned approximately $________________________ per month. [date of last employment] [salary] 4. I have received income from the following sources in the past 12 months (check all that apply): Income from a business, profession, or other self-employment. The amount of income I received in the past 12 months from this income source was approximately $__________________________. The work that I performed was __________________________________________________________________. [amount of income] [describe the type of work performed for this source of income] Income from rent payments. The amount of income I received in the past 12 months from this income source was approximately $__________________________. I have __________________________ rental properties. [amount of income] [number of properties] Income from interest or dividends. The amount of income I received in the past 12 months from this income source was approximately $__________________________. The interest and/or dividend income was from __________________________________________________________________. [amount of income] [describe the source of interest and/or dividend income] Income from other sources. The amount of income I received in the past 12 months from other income sources was approximately $__________________________. The other income was from __________________________________________________________________. [amount of income] [describe the source of any other income] 5. My assets are as follows (check all that apply): I have cash in the amount of $__________________________. [amount of cash] I have a checking account(s) with a balance of $__________________________. [balance of checking account(s)] I have a savings account(s) with a balance of $__________________________. [balance of savings account(s)] [value of real estate] I own real estate with an approximate value of $__________________________. This property is _____________________________________________________________. [describe the real estate property] I own a vehicle(s) with an approximate value of $__________________________. The vehicle(s) is _____________________________________________________________. [value of vehicle(s)] [describe the vehicle, including type of vehicle, make, model, year] [list the items of valuable property] I own other valuable property with an approximate value of $__________________________. This property is _______________________________________________. [value of other valuable property] Note: Affidavit is continued on the other side. Additional documentation pertaining to this affidavit may be attached. American LegalNet, Inc. www.FormsWorkFlow.com 6. The following people are dependent upon me for support (list dependents and relationship): Name of Person Relationship ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ 7. Type of Expense ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ Amount My monthly expenses are (list expenses, such as rent or house payment, and the approximate amount of each expense): ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ 8. I have additional financial circumstances that I would like the court to consider as part of my request: __________________________________________________________________. [list any additional financial issues] I have attached additional information or documentation in support of my request. Therefore, pursuant to Neb. Rev. Stat. §48-182, I am requesting permission to proceed without prepayment of fees and costs or security. I hereby swear, or affirm, under penalty of perjury, that the foregoing affidavit is true. ___________________________________________________________________________________________ [sign your name] ___________________________________________________________________________________________ [print your street address] ___________________________________________________________________________________________ [print your telephone number] ___________________________________________________________________________________________ [print your full name] ___________________________________________________________________________________________ [print your city, state, & zip code] Note: Please keep the court informed if you change your address or phone n