Affidavit And Application Form To Proceed In Forma Pauperis ) (Request To Proceed Without Payment Of Fees) Page 2

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5.
My only assets or resources, over which I have control or possession, are:
Cash on hand ............................................................................................ $
Bank accounts ........................................................................................... $
Vehicles ..................................................................................................... $
Real estate ................................................................................................. $
Securities, stocks, bonds ........................................................................... $
Tools, equipment ....................................................................................... $
Jewelry ...................................................................................................... $
Other .......................................................................................................... $
TOTAL ...................... $
6.
My necessary estimated monthly expenses are:
Rent or house payment .............................................................................. $
Utilities (Electricity, natural gas, propane) .................................................. $
Telephone .................................................................................................. $
Automobile payment (monthly) ................................................................... $
Automobile insurance (monthly) ................................................................. $
Gasoline for vehicle ................................................................................... $
Auto upkeep and repair .............................................................................. $
Doctor, dentist, medicines .......................................................................... $
Food .......................................................................................................... $
Cable TV, internet, etc. .............................................................................. $
Clothing, dry cleaning, laundry ................................................................... $
Haircuts...................................................................................................... $
Church ....................................................................................................... $
Entertainment ............................................................................................ $
Personal care items ................................................................................... $
Other (Credit cards, etc.) ............................................................................ $
TOTAL ...................... $
Affidavit and Application to Proceed In Forma Pauperis, DC 6:7(1),
2
PSC Nebraska, Rev. 5/10, Neb. Rev. Stat. 25-2301 to 25-2310.

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