STATE OF NEBRASKA FORM NO. DC1 New 9/97 Neb. Rev. Stat. ' 42-371.01 CASE NUMBER: CHILD SUPPORT TERMINATION APPLICATION AND AFFIDAVIT IN THE DISTRICT COURT OF COUNTY, NEBRASKA APPLICATION AND AFFIDAVIT TO OBTAIN TERMINATION OF CHILD SUPPORT Petitioner vs. Respondent I, , obligor, hereby swear that the child, , D.O.B.: / / , for whom I am currently obligated to pay child support is no longer my obligation for the following reason: “ the child has reached nineteen years of age. Certified copy of birth certificate attached. Note: Child support shall continue only until the child reaches the age of majority, termination of child support is automatic providing the age and date of birth of the child is known by the court. “ the child has married. Certified copy of marriage license and certificate of marriage attached. “ the child has died. Certified copy of death certificate attached. “ the child has been emancipated by an order from: ,a court of competent jurisdiction. Certified copy of the court order attached. I hereby request that my child support obligation for the above child be terminated on the day of , . I hereby request that the clerk of court send a copy of this application to the last known address of the obligee, which is . Obligee=s: (Street) (City) (State) (Zip) I understand that if there is any unpaid child support obligations, principal and interest, owed prior to the requested date of termination, this termination does not relieve those prior obligations. In the event the obligee does not file an objection within thirty days after the clerk=s notice to the obligee was mailed, I hereby request that the child support for the above child be terminated by court order as requested. I hereby swear, or affirm, under penalty of perjury, that the foregoing affidavit is true. Signature of Obligor . Obligor=s: (Street) Subscribed and sworn on oath before me on this Clerk of District Court/Notary Public (City) (State) day of (Zip) , . (Seal) CLERK'S SERVICE OF NOTICE ON OBLIGEE AND ASSIGNEE A true and accurate copy of this application and affidavit to obtain termination of child support was sent by the clerk of the district court to: 1.) “ the obligee at the above address, and to: 2.) “ the Department of Health and Human Services if there is an active assignment of support, by depositing copies thereof in the U.S. mail, postage prepaid on this day of , . Clerk of Court: ____ NOTICE TO OBLIGEE The court shall terminate child support if no written objection has been filed within thirty days after the date the clerk's notice to the obligee was mailed, the forms and procedures have been complied with, and the court believes that a hearing on the matter is not required. As obligee, if you do not file a written objection within thirty days after the date the notice was mailed, child support for this child may be terminated without further notice to you. This form is provided by the State Court Administrator as required by Neb. Rev. Stat. ' 42-371.01 RRS 1943 but should be reviewed by your attorney. American LegalNet, Inc. www.FormsWorkflow.com