Free Addendum 3 - Nebraska

IN THE NEBRASKA WORKERS' COMPENSATION COURT THIS DOCUMENT IS CONFIDENTIAL AND SHALL NOT BE MADE PART OF THE COURT FILE OR PROVIDED TO THE PUBLIC PURSUANT TO WORKERS' COMP. CT. R. OF PROC. 2. __________________________________, Plaintiff, ) ) ) ) ) ) ) ) ) ) DOC: NO:

PERSONAL AND FINANCIAL ACCOUNT INFORMATION

vs. __________________________________, Defendant.

Employee Social Security Number Employee Date of Birth (if applicable to this case)

___________________ ___________________

Minor Children (if applicable to this case) Name __________________ __________________ __________________ Social Security Number _____________________ _____________________ _____________________ Date of Birth ___________ ___________ ___________

Protected financial account information (if applicable to this case) Entity/Person Type of Account Account Number

________________

__________________

___________________

(add additional pages as necessary)

Addendum 3