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):
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

Check to waive
All Interest

 

 

 

 

 

1. _____________________

______

____/____/_____

$ ____________

_____

 

 

 

 

 

2. _____________________

______

____/____/_____

$ ____________

_____

 

 

 

 

 

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

_____________________________________________
Notary Public/Clerk of Court

 

* * * * * FOR OFFICE USE ONLY - DO NOT FILL OUT BELOW THIS LINE * * * * *

 

 

Payor Name: _______________________________

Payor SSN: xxx/xx/______

 

 

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_____.

 

_______________________________________
District Judge/Clerk/or Designee

 

 

CSE Finance use only:

Target __________

Man Dist __________

 

 

CSE Finance Acknowledgement

CC ID: ___________________________

Transaction Completed

 

 

Bucket: ___________________________

Processors initials: _____________

 

Date: _________________________

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.