State Of Nebraska Small Claims Certified Mail Return
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1
2Nebraska State Court Form
CC 4:5
Revised 05/16
SMALL CLAIMS
REQUIRED
Neb. Rev. Stat. 25-2804(3)
CERTIFIED MAIL RETURN
IN THE COUNTY COURT OF ________________COUNTY, NEBRASKA
Case #____________________
Plaintiff
vs.
SMALL CLAIMS
CERTIFIED MAIL RETURN
Defendant
I acknowledge that a copy of the small claims complaint was mailed to each defendant by
certified mail, return receipt requested.
Defendant:
Case Number:
Trial Date:
1. Certified mail was mailed on
2. Return receipt was signed on
3. Certified mail was returned unsigned on
4. Postage $
Date
Signature
Name (Plaintiff)
Street Address/P.O. Box
City/State/ZIP Code
Phone
E-mail Address
Small Claims Certified Mail Return
CC 4:5 Rev. 05/16
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