Form DC6:7(1) "Affidavit and Application to Proceed in Forma Pauperis (Request to Proceed Without Payment of Fees)" - Nebraska

What Is Form DC6:7(1)?

This is a legal form that was released by the United States District Court for the District of Nebraska - a government authority operating within Nebraska. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on August 1, 2017;
  • The latest edition provided by the United States District Court for the District of Nebraska;
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  • Fill out the form in our online filing application.

Download a fillable version of Form DC6:7(1) by clicking the link below or browse more documents and templates provided by the United States District Court for the District of Nebraska.

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Download Form DC6:7(1) "Affidavit and Application to Proceed in Forma Pauperis (Request to Proceed Without Payment of Fees)" - Nebraska

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Nebraska State Court Form
AFFIDAVIT AND
APPLICATION TO PROCEED
DC 6:7(1) Rev. 08/17
IN FORMA PAUPERIS
Neb. Rev. Stat. §§ 25-2301
(Request to Proceed Without
to 25-2310.
Payment of Fees)
IN THE
COURT OF __________________COUNTY, NEBRASKA
_________________________________________
(County or District)
(county where original petition filed)
____________________________,
Case No. _______________
(your full name or the name of the plaintiff in the original action)
(case number assigned by clerk of court)
Plaintiff,
AFFIDAVIT AND APPLICATION
vs.
TO PROCEED IN FORMA PAUPERIS
(Request to Proceed Without
____________________________,
Payment of Fees)
(other party's full name or the name of the defendant in the
original action)
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/
defendant in an action to/f or ____________________________ _ ,
and I am of lawful age.
(type of case filed)
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 service and/or publication,
and am unable to provide security.
I have a net income of $____________________ per month, derived from
4.
(your net monthly income)
________________________________, and I support a household of ________ people.
(number of people you support)
(i.e., employment, public benefits, Social Security, etc.)
Page 1 of 3
Affidavit and Application to Proceed in
Forma Pauperis
DC 6:7(1) Rev. 08/17
Nebraska State Court Form
AFFIDAVIT AND
APPLICATION TO PROCEED
DC 6:7(1) Rev. 08/17
IN FORMA PAUPERIS
Neb. Rev. Stat. §§ 25-2301
(Request to Proceed Without
to 25-2310.
Payment of Fees)
IN THE
COURT OF __________________COUNTY, NEBRASKA
_________________________________________
(County or District)
(county where original petition filed)
____________________________,
Case No. _______________
(your full name or the name of the plaintiff in the original action)
(case number assigned by clerk of court)
Plaintiff,
AFFIDAVIT AND APPLICATION
vs.
TO PROCEED IN FORMA PAUPERIS
(Request to Proceed Without
____________________________,
Payment of Fees)
(other party's full name or the name of the defendant in the
original action)
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/
defendant in an action to/f or ____________________________ _ ,
and I am of lawful age.
(type of case filed)
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 service and/or publication,
and am unable to provide security.
I have a net income of $____________________ per month, derived from
4.
(your net monthly income)
________________________________, and I support a household of ________ people.
(number of people you support)
(i.e., employment, public benefits, Social Security, etc.)
Page 1 of 3
Affidavit and Application to Proceed in
Forma Pauperis
DC 6:7(1) Rev. 08/17
5.
My only assets or resources, over which I have control or possession, are:
Cash on hand .................................................................................................$
Bank accounts ...............................................................................................$
Vehicles ..........................................................................................................$
Real estate .....................................................................................................$
Securities, stocks, bonds ...............................................................................$
Tools, equipment ...........................................................................................$
Jewelry ...........................................................................................................$
Other (describe).........................................................................................$
___________________________________________________________
___________________________________________________________
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 (describe)..............................................................................................$
___________________________________________________________
___________________________________________________________
TOTAL .......................$
Page 2 of 3
Affidavit and Application to Proceed in
Forma Pauperis
DC 6:7(1) Rev. 08/17
7.
Other financial circumstances of which I would like the court to be aware:
I believe my living expenses wholly absorb my income, and I have no assets that
8.
can be liquidated.
WHEREFORE, pursuant to Neb.Rev.Stat. §§ 25-2301 to 25-2310, I request 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.
NOTICE: DO NOT SIGN UNTIL YOU ARE IN THE PRESENCE OF A NOTARY
Date
Plaintiff’s Signature (your signature)
Your Full Name
Your Full Street Address/P.O. Box
City/State/ZIP Code
Phone
E-mail Address
SUBSCRIBED AND SWORN to before me this ___day of _______________, 20___.
________________________________
Notary Public
Page 3 of 3
Affidavit and Application to Proceed in
Forma Pauperis
DC 6:7(1) Rev. 08/17
Page of 3