Free 2009/2010 Assessment Form - Nebraska

UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEBRASKA

2009/2010 BIENNIAL ASSESSMENT FORM
(Pro hac vice attorneys are not required to fill out a biennial assessment form or pay the $10.00 assessment fee.) 1. Please supply our office with the following information: Name _____________________________________________________________ Mailing Address _____________________________________________________ __________________________________________________________________ Law Firm Telephone Number ___________________________________________ Law Firm Fax Number ________________________________________________ E-mail Address ______________________________________________________ 2. The Federal Practice Committee decided at its August 15, 2008, meeting to compile a current list of attorneys who are willing to accept appointments in civil in forma pauperis cases. For information regarding compensation of court-appointed counsel, please see the court's Amended Plan for the Administration of the Federal Practice Fund available on the court's W eb site: http://www.ned.uscourts.gov/pom/crtplans/fedpract.pdf. In conjunction with the renewal process, we are asking the following question: Are you willing to accept appointments in civil in forma pauperis cases? Yes __________ 3. No __________

If paying by check, make payable to Clerk, U.S. District Court. If paying by credit card, complete the bottom portion of this form. Please complete the form and return with your $10.00 payment to: Clerk, U. S. District Court Biennial Assessment 111 S. 18th Plaza, Suite 1152 Omaha, NE 68102-1322

Credit Card Authorization: I, Name of Attorney/Law Firm __________________________ hereby authorize the United States District Court for the District of Nebraska to charge the following credit card for payment of the assessment fee in the amount of $_______________ Credit Card Number ___________________________ ________________
Forms-Attorney_Assessment_2009_2010.wpd Approved: December 8, 2008

Exp Date ________________

If using an American Express card, please provide the 4-digit ID number