Affidavit And Application Form To Proceed In Forma Pauperis ) (Request To Proceed Without Payment Of Fees)

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IN THE
COURT OF _________________ COUNTY, NEBRASKA
(county or district)
(county where Complaint filed)
____________________________,
)
Case No. CI _____________
)
(your full name)
(case number assigned by Clerk of Court)
Plaintiff,
)
AFFIDAVIT AND APPLICATION
)
TO PROCEED IN FORMA PAUPERIS
vs.
)
)
(Request to Proceed Without
____________________________,
)
Payment of Fees)
)
(spouse’s full name)
Defendant.
)
STATE OF NEBRASKA
)
) ss:
COUNTY OF ___________________
)
(county where signed)
The undersigned, being first duly sworn on oath, deposes and says that:
1.
I am the plaintiff in an action for _________________________, and I am of
(type of case filed)
lawful age.
2.
I bring this action in good faith, and I am entitled to redress.
3.
I am unable to pay the cost of litigation, including the cost of publication,
and am unable to provide security.
4.
I have a net income of only $____________________ per month,
(your net monthly income)
derived from ________________________________,
(i.e., employment, public benefits, Social Security, etc.)
and I support a household of ________ people.
(number of people you support)
Affidavit and Application to Proceed In Forma Pauperis, DC 6:7(1),
1
PSC Nebraska, Rev. 5/10, Neb. Rev. Stat. 25-2301 to 25-2310.

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