The Nebraska Supreme Court requires that this form be completed and filed no later than May 1 of each year. For instructions on completing the form, see Appendix C
Filing for Calendar Year Ending December 31, Year.
I am a judge serving the: Choose an item. OR I am a: Choose an item. ☐ I worked in more than one role this year. Previously I was a judge serving the: Choose an item. OR Previously I was a Choose an item. The previous role ended on: Click or tap to enter a date.
Judicial District (if applicable): Judicial District. If you do not have an assigned Judicial District enter “N/A”
ITEM 1 – Name, office address, telephone number, email address: Last Name. First Name. M.I.
Last Name	First Name	M.I.
Office Address.
Office Address
City.	NE	ZIP code	( xxx ) Phone
City	State	Zip Code	Telephone Number
Email
Email Address

ITEM 2 – Compensation for extrajudicial activities as permitted by Rule 3.12 (do not report item where the amount or value of such item, alone or in the aggregate with other items received from the same source in the same calendar year, does not exceed $100) (Rules 3.15(A)(1) and 3.15(C)):
Date	Place	Nature of Activity	Payor	Amount of Compensation

ITEM 3 – Gifts and other things of value as permitted by Rule 3.13(C) (do not report item where the amount or value of such item, alone or in the aggregate with other items received from the same source in the same calendar year, does not exceed $100) (Rules 3.15(A)(2) and 3.15(C)):
Name and Address of Donor	Occupation or Nature of Business of Donor	Description of gift, loan, bequest, benefit, or other thing of value accepted	Value

ITEM 4 – Reimbursement of expenses and waiver or partial waiver of fees or charges as permitted by Rule 3.14(A) (do not report if amount of reimbursement or waiver, alone or in the aggregate with other reimbursements or waivers received from the same source in the same calendar year, does not exceed $100) (Rules 3.15(A)(3) and 3.15(C)):
Name of Funding Source	Type or Purpose of Funding (“reimbursement of expense” or “waiver of fee”)	Amount or Value Received

ITEM 5 – Compensation, fees, honorarium, gratuities, gifts, or contributions, regardless of amount, received for marriage ceremonies performed as permitted by Rule 3.16 (Rules 3.15(A)(4) and 3.15(C)):
Date & Place of Marriage	Names of Persons Married	Name(s) of Payor(s)	Amount Received

ITEM 6 -- Real property in the judge’s name or in which the judge has a direct ownership interest, EXCEPT real estate valued at less than $1,000 and the judge’s personal residential real estate (“Personal residential real estate” refers to the judge’s principal and/or recreational dwelling-house and adjacent land used for household or recreational purposes, such as lawns and gardens.): (Rule 3.15(B)(1)) (For each tract, describe only the county and state where the property is located.)
Location	Nature of Property (i.e., agricultural, commercial, residential-rental)

ITEM 7 – Other financial interests and property held during the reporting period (Rule 3.15(B)(2)): Report only items which have a fair market value of $1,000 or more.
A. List the names and addresses of the institutions in which you had checking and savings accounts and certificates of deposit.
Financial Institution	Address

B. List the names of the issuers of all stocks, bonds, and government securities that you own. Names of the issuers of all stocks.

C. Describe the property owned or held for the production of income not otherwise disclosed in this statement. Include leaseholds and other interests in real estate, promissory notes, and other obligations owed to you, beneficial interests in trusts and estates, cash value life insurance, IRAs, deferred income and retirement plans. DO NOT INCLUDE benefits offered by the State of Nebraska to its employees, including retirement plans, deferred compensation plans, health savings accounts, and flexible spending accounts; household goods; personal automobiles; and other tangible personal property unless such property was held primarily for sale or exchange. Description of property.

ITEM 8 – Creditors to whom $1,000 or greater was owed or guaranteed by you or a member of your family residing in your household, EXCEPT: (a) loans from a member of the judge’s family*; (b) land contracts which have been recorded with the County Clerk or Register of Deeds; and (c) accounts payable, debts arising out of retail installment transactions, and loans from lending institutions in their regular course of business, if such accounts, debts, and loans are made available on the same terms to similarly situated persons who are not judges (Rules 3.13(C) and 3.15(B)(3)):
Name	Address	Amount or Value Owed or Guaranteed

ITEM 9 – Signature of Judge and Date Date Click or tap to enter a date. Signature /s/ The typed signature is the equivalent of a manual signature