Clerk of the District Court

PO Box 347

Stanton NE 68779

RE:	Court Case #
	Custodial Parent:
	Non-Custodial Parent:

I, _____________________________, want to give _____________________________

(Custodial Parent’s Name) (Non-Custodial Parent’s Name)

credit for the child support due and owing for the following month(s): _____________________

(Month/Year)

in the amount of $ _____________________.

I understand that this receipt does not give credit for any assigned child support and interest due and owing to the State of Nebraska.

Dated this _____ day of _____________________, ______.

___________________________________

(Custodial Parent’s Signature)

STATE OF NEBRASKA )

) §

County of _______________)

Subscribed and sworn to before me this _____ day of ___________________, ______.

(seal) ___________________________________

Notary Public