Payee Affidavit For Non-Monetary Receipt Instructions
Clerk of the District Court
The non-custodial party is always responsible for abiding by the terms of his/her current support court order. However, the Non-Monetary Receipt form is to be used when the court allows a non-custodial party to receive credit for payments made directly to the payee, or for the payee to waive or forgive court ordered support. This form is the instrument to convey information regarding those credits from the Clerk of the District Court Office to Child Support Enforcement (CSE) - Finance for entry into the official case record. It combines the payee affidavit with the Clerk of the District Court’s non-monetary receipt form.
Payees are encouraged to submit the form in a timely manner to the Clerk of the District Court. Delays in reporting may cause enforcement and distribution problems. Some payees attempt to report multiple payments or credits at one time, therefore, several lines have been provided on the form to report multiple transactions.
This form will not replace the current form for court ordered credits, release of liens or credit for payments made in another state, etc.
Clerk of the District Court Requirements:
Completing the Form:
Part 1 Request
To Be Completed by the Payee.
1a. Name of the state where the payee is completing the Receipt.
1b. Name of the county where the payee is completing the Receipt.
1c. Payee’s Name.
1d. Payee’s case number.
Payee will select Section A and/or Section B with a check mark. Information may be entered in Section A or Section B or both sections if the payee received a direct payment and wishes to waive additional support.
It is important that the payee complete the correct section, either A or B, for their situation. Completing the wrong section for example could result in creating a recovery for money the payee did not receive, and/or failure to give the non-custodial party credit for money paid to the payee, etc.
Part 2 Acknowledges the Payee’s Receipt of Direct Payments
The payee will complete this section when he/she receives direct payment from the
the non-custodial party and he/she wishes to have credit given to the non-custodial
2a. Check Section A for Direct Payments.
2b. Type of Support, the payee will list one type of support per line, i.e. child, spousal or medical.
2c. Judgment No.- This field is for the Clerk’s use only. Clerks will fill in the
judgment group-guideline groups. The field should display the code value 2-1, 3-1, 4-1, etc. that correspond to the type of support listed in column 2b.
2d. Date of Payment – The payee will fill in month/day/year that the direct payment is to be credited on the non-custodial party’s ledger. A direct payment can not have a future effective date as the payment is to reflect a transaction that has already occurred.
2e. Amount of Payment – The payee will fill in the total amount of the direct payment for the date of the payment placed in field 2d.
The payee should repeat steps 2a – 2e on lines 2 and 3 for additional direct payments which are different in type or for a different date of payment.
The payee should read the statement following on the form, “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.)”
This statement puts the payee on notice that credit for the direct payment may or may not be given, in accordance with federal and state law and regulation and the usual policy of the court. The decision to allow a credit will depend on the following: the payee’s status as a current or former recipient of ADC or foster care funds, if the support has been assigned to the state and if the direct payment exceeds the amount due on the payment date.
Part 3 Acknowledges the Payee’s Request to Waive/Credit Support
The payee will complete Section B when the payee wishes to waive or forgive some or all of the support due on a particular date.
3a. Check Section B to Waive/Credit support when Payee received no actual cash payment.
3b. Type of Support – The payee will list one type of support per line, i.e. child, spousal or medical.
3c. Judgment Number – This field is for the Clerk’s use only. Clerks will fill in all applicable judgment group – guideline groups. The field should display the code value 2-1, 3-1, 4-1, etc., that corresponds to the type of support listed in column 3b.
3d. Date of Credit – The payee will fill in the month/day/year that the amount is to be waived/credited on the non-custodial party’s ledger.
3e. Enter Amount of Credit or “All” – The payee will fill in the total amount to be waived or credited on the Date of Credit. “ALL” will waive current, delinquent, arrears and interest owed on the Date of Credit.
3f. Check box to waive ALL interest. If the payee checks this box, all interest due the payee on the date of credit will be waived, regardless of the amount entered in 3e.
The payee should repeat steps 3a – 3f on lines 2 and 3 if there are other types of support they wish to waive/credit.
The payee should read the statement following on the form that, “If a portion of the support funds you are waiving or crediting (forgiving) are due to the State of Nebraska, 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.”
This statement puts the payee on notice that they will not be allowed to waive state debt in accordance with federal and state law and regulation.
The payee should read the last paragraph on page 1 that states:
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.
Neither Clerks of the District Court nor Child Support Enforcement can offer legal advice to the payee regarding this form. This statement directs the payee to discuss questions with their attorney. For questions regarding whether their support has been assigned to the State of Nebraska or another state, the customer service center will assist them.
If CSE office staff assist a payee in filling out the receipt, staff must confirm that all information is accurate and complete.
Part 4 Informational
The payee must PRINT the requested information about him/her self and the non- custodial party.
4a. Payee’s name and address.
4b. Non-custodial party’s name and address.
This information will be used by the Clerk to update their files and to contact the payee if the form is not completed satisfactorily.
Part 5 Notary
5b Payee signs in front of notary or clerk (Some counties allow the Clerk to witness the signing of an affidavit if they know the individual.)
ØThe payee does not complete any information on the form after this point.
To be completed by Notary or Clerk.
5c. Numerical Date.
5f. Signature of Notary or Clerk.
Apply Notary Seal, if applicable.
Part 6 Clerk’s Use Only Box
To be completed by the Clerk.
6a. Payor’s Name (print).
6b. Last four digits of Payor’s Social Security Number.
6c. FIPS number. This field may be pre-filled with the county’s FIPS before making it available for use.
6d. Court Case Number.
If the information in 6a – 6d is not consistent with other information in the receipt, the information provided by the Clerk will be used by CSE Finance to give the credit.
Part 7 Application of Credit
To be completed by the Clerk. If the Clerk intends to complete 7a and 7b with the same responses on all forms, fields 7a and 7b may be pre-filled with the court’s responses before making copies the form.
7a. 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. □ Y □ N
If the affidavit requests credit for a direct payment, the Clerk should complete the above with a check mark in the Y or N box.
Y means that a direct payment greater that the amount of support due on the date of payment would generally be credited to the non-custodial party’s future support obligations in their court. (For example, if a payee reported receiving $400 on 3/1/2010 but there was only $250 due on 3/1/2010, this court would allow the $150 in excess of the amount due to be credited to the non-custodial parent’s future obligation.)
N means that the $150 in excess of the amount due on the date of payment would NOT be credited. Some courts do not allow credit for a direct payment to a payee on an obligation that has not yet accrued.
7b. 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. □ Y □ N
If the payee requests a waiver/credit of support under Section B, the Clerk should complete the above with a check mark in the Y or N box.
Y means that waiving or forgiving support in excess of the amount due on the date of credit would generally be allowed in their court. (For example, if a payee requested waiving $400 on 3/1/2010 but there was only $250 due on 3/1/2010, this court would allow the $150 in excess of the amount due to be waived from the non-custodial parent’s future obligation.)
N means that only the $250 due on the date of credit would be waived. The $150 in excess of the amount due on the date of payment would NOT be credited. Some courts do not allow payees to waive/forgive an obligation that has not yet accrued.
7c. Clerks to provide any special instructions to CSE-Finance.
7d. Numerical date.
7g. Signature of authorized person. The Clerk or designated authorized person should sign the form if the affidavit and information completed above meet their criteria for credit to be applied to the case payment record. If the affidavit is not sufficiently complete for credit to be given or would not be an allowable credit in your court, do not sign and do not forward to CSE Finance.
Clerk will submit the document to CSE Finance. Non-monetary receipts can be mailed, faxed, or emailed to CSE Finance:
PO Box 94728
Lincoln, NE 68509
Fax 1: (402) 742-8303
Fax 2: (402) 471-7385
Part 8 CSE Finance Use Only
CSE Finance completes this section. Finance uses this section for internal processing. It also acknowledges back to the Clerk that CSE Finance has completed the requested credit, or if credit was not given, provides an explanation. Page 2 of the receipt will be returned to the Clerk to acknowledge that the transaction has or has not been completed.
8a. Processor’s initials.
8c. Target order.
8d. Manual distribution.
8e Court Case ID.
8f. Bucket designation.
8g. Reviewed by.
8i. Credit not given reason.
This section will be used to inform the Clerk if credit was not given due to state and federal regulations governing assignment of support, the usual policy of their court as indicated under the Application of Credit, or another reason.
RETURN ORIGINAL TO CLERK OF THE DISTRICT COURT, MAKE COPY FOR YOUR FILE.
(Insert mailing address of Clerk)
The Clerk may add their mailing address directly under the above statement before making copies of the form.