Nebraska Payee Affidavit for Non

PAYEE AFFIDAVIT FOR NON-MONETARY RECEIPT
STATE OF NEBRASKA
COUNTY OF SCOTTS BLUFF
COMES, now __________________________(your name), and I hereby notify the court and the
Nebraska Department of Health and Human Services Child Support Enforcement Unit that in case
number CI__________________:
Please Check and Complete Section A for Direct Payments and/or Section B to Waive or Credit Payments.
____________________________________________________________________________________
_____ A.
I wish to acknowledge direct payments (money received by you):
Type of Support (one per line):
Child, Spousal, Medical
Judgment No.
(clerks use)
Date of Payment
(mo/day/yr)
Amount
of Payment
1. ______________________
_______
____________
$__________
2. ______________________
_______
____________
$__________
3. ______________________
_______
____________
$__________
Any payments that you receive which are in excess of the amount owed to you may be considered a gift and may
not be credited to the support due. (Excess payments are allocated at the discretion of the court)
_____ B.
I wish to waive/credit the following amounts (no actual cash received):
Type of Support (one per line):
Child, Spousal, Medical
Judgment No.
(clerks use)
Date of Credit
(mo/day/yr)
Amt of Credit
or “All”
9 to waive
All Interest
1. _____________________
_______
__________
$_______________
2. _____________________
_______
__________
$_______________
3. _____________________
_______
__________
$_______________
If a portion of the support funds you are waiving or crediting (forgiving) are due to t he State of Nebraska as a
result of you or the dependents in the above court case receiving ADC/foster care funds, please be advised that
you may not waive or credit (forgi ve)any of these funds due to the State. Only the State of Nebraska has the
authority to waive or credit (forgive) support funds due to the State.
The Clerk of the District Court and the Nebraska Department of Health and Human Services Child
Support Enforcement Unit accept no responsibility for the contents of this receipt. If you have any
questions about signing this form please contact your attorney. If you have any questions regarding debt
owed to the State of Nebraska, please call Child Support Customer Service at 1-877-631-9973.
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Print your name and address:
_________________________________________________________________________________________________
Print non-custodial party (person ordered to pay support) name and address:
_________________________________________________________________________________________________
I acknowledge and affirm that this is my voluntary act made without coercion, fraud or threat.
Date: ______________
Signed: _____________________________
SUBSCRIBED AND SWORN to before me this ____ day of ____________, 20___.
Seal
__________________________________________________________
Notary Public/Clerk of Court
* * * FOR OFFICE USE ONLY - DO NOT FILL OUT BELOW THIS LINE * * *
Payor Name: _______________________________
FIPS Number: 31157
Payor SSN: __XXX – XX- __________
Court Case Number: CI________________________
_________________________________________________________________________________
Application of Credit
For Direct Payments under Section A:
It is the usual policy of this court to allow credit for direct payments that will apply to future
obligations owed to the payee. NN No
For Waiver/Credit under Section B:
It is the usual policy of this court to allow a payee to waive or forgive support
obligations that have not accrued. No
Special instructions: ________________________________________________________________
I direct that the above credit be applied to the case payment record.
Dated this ______ day of ____________________, 20___.
_______________________________________
District Judge/Clerk/or Designee
CSE Finance use only:
Target _______
CSE Finance Acknowledgement
Transaction Completed
CC ID ______________________________
Processor’s initials __________
Date _____________________
Man Dist __________
Bucket _____________________________
Reviewed by _________________________
Date ______________________________
Credit not given reason:
FAX To CSE Finance: (402) 471-7385
____________________________________________________________________________________
RETURN ORIGINAL TO: CLERK OF THE DISTRICT COURT, MAKE COPY FOR YOUR FILE.
P.O. BOX 47, GERING, NE 69341-0047
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