Affidavit And Application Form To Proceed In Forma Pauperis ) (Request To Proceed Without Payment Of Fees) Page 3

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7.
Other financial circumstances of which I would like the court to be aware:
8.
I believe that my living expenses wholly absorb my income, and that I have no assets
which can be liquidated.
WHEREFORE, pursuant to Neb.Rev.Stat. §§ 25-2301 to 25-2310, I request that
the Court authorize me to proceed in forma pauperis and direct __________________________
(name of county where action
filed)
County, Nebraska, to pay my costs, including fees and other expenses related to this
action and waive provision of security.
________________________________
Plaintiff (print name)
________________________________
Signature
SUBSCRIBED AND SWORN to before me this ___day of _______________, 20___.
________________________________
Notary Public
Affidavit and Application to Proceed In Forma Pauperis, DC 6:7(1),
3
PSC Nebraska, Rev. 5/10, Neb. Rev. Stat. 25-2301 to 25-2310.

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