NSC Attorney Services Division - Phone: 402.471.3137 - Fax: 402.471.0728 - Email: [email protected] TRUST ACCOUNT AFFIDAVIT STATE OF NEBRASKA County of ) ) _ ) ss. If your membership status is Regular Active, Junior Active, Senior Active, or Military Active, and you have an office in Nebraska, you must complete this form. AFFIDAVIT Judicial Active members are not required to complete this form. , BEING FIRST DULY SWORN ON OATH, STATES AS FOLLOWS: (Print Name Here) I am an attorney duly licensed to practice law in the State of Nebraska, and I am familiar with the provisions of the Nebraska Supreme Court Rules and Neb. Rev. Ct. R. § 3-501.15, requiring: 1) that all lawyers holding funds of clients or third persons must maintain a separate account for such funds (commonly known as a trust account) 2) that every lawyer maintaining a trust account containing client funds of a nominal amount or held for a short period of time must participate in the Interest On Lawyers Trust Account (IOLTA) Program unless a written Notice of Declination is submitted to the Chief Justice of the Supreme Court by February 15 of the year to which the Notice of Declination will apply 3) certain reporting and production by approved financial institutions in regard to overdrafts of trust accounts ATTORNEYS WHO DO NOT HANDLE CLIENT FUNDS: I am EXEMPT from the provisions of these rules because I do not maintain a trust account and I handle no funds of clients or third persons and do not expect to receive funds of clients or third persons within the next twelve (12) months. ATTORNEYS WHO HANDLE CLIENT FUNDS: I, or my firm, maintain one or more trust accounts for the deposit of funds from clients or third persons. I will participate in the Interest On Lawyers Trust Accounts (IOLTA) Program for the accounts listed below that are specifically identified as IOLTA accounts. I certify that the following information pertaining to said accounts is true and accurate, and grant the following authorizations. Law Firm Reporting: A firm may complete one affidavit (retyped on firm letterhead, signed by a partner) for all attorneys in the firm. It must list all the attorneys (and their Bar numbers) in the firm, or covered by the affidavit, and contain the same affirmations as this form, identifying all trust accounts, if they are IOLTA accounts, and the names and addresses of all persons authorized to sign checks or make withdrawals. Supreme Court Rules and other information can be found at Neb. Ct. R. §§ 3-901 to 3-907. NAME OF FINANCIAL INSTITUTION & ADDRESS NAME ON ACCOUNT ACCOUNT NO. IOLTA (Please circle) Yes No* Yes No* Yes No* * Circling "No" may require filing be made pursuant to Neb. Ct. R. § 3-903(C) to effect a declination. Below: List names and addresses of all persons authorized to sign checks or make withdrawals on each account. Authorization to Financial Institutions IOLTA Participation: For all accounts listed above where I have indicated "Yes" under "IOLTA," I hereby authorize such financial institution in which I maintain a trust account for client funds or third persons to automatically, and without further documentation, convert my trust account described above to an interest-bearing IOLTA account subject to the provisions of the Nebraska Supreme Court Rules. In summary, the financial institution is specifically authorized and directed to remit the interest earned, less customary services or charges, to the Nebraska Lawyers Trust Account Foundation. The Taxpayer Identification Number certification (IRS Form W-9 and 1099 information returns), if required, will show the Nebraska Lawyers Trust Account Foundation, PO Box 95103, Lincoln, NE 68509, Taxpayer I.D. No. 36-3357241, as the recipient of interest. Automatic Notice of Trust Account Overdrafts: I hereby consent to the release by the financial institution referenced above of information associated with the trust account(s) maintained at said financial institution for purposes of complying with the reporting and production requirements mandated by the Trust Account Overdraft Notification Rules as adopted by the Nebraska Supreme Court. All such notices must be sent to the Counsel for Discipline, 3808 Normal Blvd., Lincoln, NE 68506. Attorney or Firm Name: Address: Bar Number: ___________________________________________ Signature: ___________________________________________ ________________________________ SUBSCRIBED AND SWORN TO before me this ____________ day of ______________________,_20_____ Notary Public: _______________________________________ APPENDIX 1 This form must be signed and notarized.
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