Payee Affidavit For Non-Monetary Receipt Form
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2PAYEE AFFIDAVIT FOR NON-MONETARY RECEIPT
STATE OF NEBRASKA
COUNTY OF LANCASTER
COMES, now __________________________(
), and I hereby notify the court and the
your name
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):
Judgment No.
Date of Payment
Amount
Child, Spousal, Medical
(clerks use)
(mo/day/yr)
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):
Judgment No.
Date of Credit
Amt of Credit
to waive
Child, Spousal, Medical
(clerks use)
(mo/day/yr)
or “All”
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.
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