PAYEE AFFIDAVIT FOR
NON-MONETARY RECEIPT
STATE
OF _______________________)
COUNTY OF _____________________)
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): |
Judgment
No. |
Date
of Payment |
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1. ________________________ |
__________ |
____/____/_____ |
$
____________ |
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2. ________________________ |
__________ |
____/____/_____ |
$
____________ |
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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): |
Judgment
No. |
Date
of Credit |
|
Check
to waive |
|
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1.
_____________________ |
______ |
____/____/_____ |
$ ____________ |
_____ |
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2.
_____________________ |
______ |
____/____/_____ |
$ ____________ |
_____ |
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3.
_____________________ |
______ |
____/____/_____ |
$ ____________ |
_____ |
If
a portion of the support funds you are waiving or crediting (forgiving) are due
to the 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 (forgive) 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.
|
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 |
_____________________________________________ |
* * * * * FOR
OFFICE USE ONLY - DO NOT FILL OUT BELOW THIS LINE * * * * *
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Payor Name: _______________________________ |
Payor SSN: xxx/xx/______ |
|
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FIPS
Number: ____________________ |
Court
Case Number: _________________ |
|
|
|
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. _____ Yes _____ 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. _____ Yes _____ No
Special
instructions: ________________________________________________________________
I
direct that the above credit be applied to the case payment record.
|
Dated this ______ day of
____________________, 20_____. |
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_______________________________________ |
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CSE Finance use
only: |
Target
__________ |
Man
Dist __________ |
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CSE
Finance Acknowledgement |
CC
ID: ___________________________ |
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Transaction
Completed |
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Bucket:
___________________________ |
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Processors
initials: _____________ |
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Date:
_________________________ |
Reviewed
by: ______________________ |
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Date:
_____________________________ |
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Credit
not given reason: |
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__________________________________________________________________________________ |
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FAX
To CSE Finance: (402) 471-7385 |
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RETURN ORIGINAL TO CLERK OF THE DISTRICT
COURT, MAKE COPY FOR YOUR FILE.