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Fill and Sign the Cc 61 Rev Form

Fill and Sign the Cc 61 Rev Form

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Nebraska State Court Form CC 6:1 Rev. 03/19 FINANCIAL AFFIDAVIT Neb. Rev. Stat. § 29-3902 IN THE _________________________________________ COURT OF __________________COUNTY, NEBRASKA _____________________________________ Case No.____________________ Plaintiff vs. FINANCIAL AFFIDAVIT _____________________________________ 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: Length of employment: why you cannot be employed: II. Income (Monthly) A. Wages B. Welfare C. Unemployment D. Parents E. Other Self $ $ $ $ $ III. Family Assets A. Cash on Hand B. Bank Accounts C. Automobiles D. Real Estate E. Securities, Stocks, Bonds $ $ $ $ $ IV. Address: If unemployed, state reason, physical or otherwise, Spouse $ $ $ $ $ F. G. H. I. J. Married Marital Status: Single Divorced Name of Spouse: Number of children you are supporting and their ages: Page 1 of 2 Financial Affidavit CC 6:1 Rev 03/19 Rentals Tools Equipment Jewelry Other $ $ $ $ $ Widowed V. Debts (continue on back, if needed) A. $ B. $ C. $ D. $ E. $ F. $ G. $ H. $ I. $ J. $ K. $ L. $ VI. Education Completed: Monthly Expenses (continue on back, if needed) A. $ B. $ C. $ D. $ E. $ F. $ G. $ H. $ I. $ J. $ K. $ L. $ 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 Signature Name Bar Number and Firm Name (attorneys only) Street Address/P.O. Box City/State/ZIP Code Phone State of County of E-mail Address ) ) s.s. ) Subscribed and sworn to before me on this Notary Public/Court Clerk Page 2 of 2 Financial Affidavit CC 6:1 Rev 03/19 day of My commission expires: , 20 .

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