Form CC 16:2.21 Application and Affidavit for Intervention on Behalf of the Welfare of the Ward - Nebraska

Form CC16:2.21 or the "Application And Affidavit For Intervention On Behalf Of The Welfare Of The Ward" is a form issued by the Nebraska Judicial Branch.

Download a PDF version of the Form CC16:2.21 down below or find it on the Nebraska Judicial Branch Forms website.

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Nebraska State Court Form
APPLICATION AND AFFIDAVIT
FOR INTERVENTION ON
REQUIRED
BEHALF OF THE WELFARE OF
CC 16:2.21 Rev. 11/15
THE WARD
Neb. Rev. Stat. § 30-2602.01
IN THE COUNTY COURT OF _______________ COUNTY, NEBRASKA
Case No. ____________________
IN THE MATTER OF
APPLICATION AND AFFIDAVIT
FOR INTERVENTION ON BEHALF
_________________________________
OF THE WELFARE OF THE WARD
Ward/Protected Person/Incapacitated Person
I, __________________________________, state under oath
1. That I am a person interested in the wellbeing of the ward/protected person/incapacitated person.
2. That the ward’s/protected/incapacitated person’s safety, health, or financial welfare is at issue, and these issues
are not being adequately addressed by the guardian/conservator, based upon the following facts:
___________________________________________________________________________________________
___________________________________________________________________________________________
(Attach additional pages for information or evidence)
3. I ask the court to consider the welfare of the protected person and issue an ex parte order in the protected
person’s best interest, such order to remain in full force and effect for no more than 10 days, or until a hearing can be
held on this matter.
I understand that any interested person that submits an affidavit under this section in bad faith, or submits an
affidavit that the court determines lacks a factual basis, shall be ordered to pay the opposing party reasonable
attorney’s fees and costs.
Date
Signature
Name
Street Address/P.O. Box
Bar Number and Firm Name (attorneys only)
City/State/ZIP Code
Phone
E-mail Address
State of
)
) ss.
County of
)
The foregoing instrument was acknowledged before me by
, this
Name
day of
,
.
Day
Month
Year
Notary Public (Signature of Person Taking Acknowledgment)
(Serial Number, if any)
(Title or Rank)
My commission expires:
Page 1 of 1
Application and Affidavit for Intervention On
Behalf of the Welfare of the Ward
CC 16:2.21 Rev 11/15
Nebraska State Court Form
APPLICATION AND AFFIDAVIT
FOR INTERVENTION ON
REQUIRED
BEHALF OF THE WELFARE OF
CC 16:2.21 Rev. 11/15
THE WARD
Neb. Rev. Stat. § 30-2602.01
IN THE COUNTY COURT OF _______________ COUNTY, NEBRASKA
Case No. ____________________
IN THE MATTER OF
APPLICATION AND AFFIDAVIT
FOR INTERVENTION ON BEHALF
_________________________________
OF THE WELFARE OF THE WARD
Ward/Protected Person/Incapacitated Person
I, __________________________________, state under oath
1. That I am a person interested in the wellbeing of the ward/protected person/incapacitated person.
2. That the ward’s/protected/incapacitated person’s safety, health, or financial welfare is at issue, and these issues
are not being adequately addressed by the guardian/conservator, based upon the following facts:
___________________________________________________________________________________________
___________________________________________________________________________________________
(Attach additional pages for information or evidence)
3. I ask the court to consider the welfare of the protected person and issue an ex parte order in the protected
person’s best interest, such order to remain in full force and effect for no more than 10 days, or until a hearing can be
held on this matter.
I understand that any interested person that submits an affidavit under this section in bad faith, or submits an
affidavit that the court determines lacks a factual basis, shall be ordered to pay the opposing party reasonable
attorney’s fees and costs.
Date
Signature
Name
Street Address/P.O. Box
Bar Number and Firm Name (attorneys only)
City/State/ZIP Code
Phone
E-mail Address
State of
)
) ss.
County of
)
The foregoing instrument was acknowledged before me by
, this
Name
day of
,
.
Day
Month
Year
Notary Public (Signature of Person Taking Acknowledgment)
(Serial Number, if any)
(Title or Rank)
My commission expires:
Page 1 of 1
Application and Affidavit for Intervention On
Behalf of the Welfare of the Ward
CC 16:2.21 Rev 11/15

Download Form CC 16:2.21 Application and Affidavit for Intervention on Behalf of the Welfare of the Ward - Nebraska

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