IN THE _____________COURT OF ________________COUNTY, NEBRASKA THIS DOCUMENT IS CONFIDENTIAL AND SHALL NOT BE MADE PART OF THE COURT FILE OR PROVIDED TO THE PUBLIC PURSUANT TO NEB. CT. R. OF DIST. CTS. 21. _________________, Plaintiff, v. ) ) ) ) ) ) ) ) ) ) Case Number ____________
SOCIAL SECURITY NUMBERS, GENDER, AND BIRTH DATES
________________, Defendant. Names Plaintiff: ________________ Defendant: ________________ Minor Children: ________________ ________________ ________________ ________________
Social Security Number
Gender
Birth Date
_____________________
_______
______________
_____________________
_______
______________
_____________________ _____________________ _____________________ _____________________
_______ _______ _______ _______
______________ ______________ ______________ ______________
(For other information, add pages as required.)
Appendix 3
This form is neither approved nor disapproved by any court or judicial tribunal. Use of this form provides no immunity from error.