Receipt For Specific Amount
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Receipt For Specific Amount Form. This is a Nebraska form and can be use in 3rd District Local County.
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Tags: Receipt For Specific Amount, Nebraska Local County, 3rd District
IN THE DISTRICT COURT OF LANCASTER COUNTY, NEBRASKA
(575 S. 10th Lincoln, NE 68508)
RECEIPT FOR SPECIFIC AMOUNT
CASE NUMBER _________________________
CASE TITLE
_____________________________ vs ____________________________
I hereby receipt the amount of $__________for:
_____________________________________________
(Child Support, Child Care, Spousal Support, Property Settlement)
from _____________________________on this _________ day of ____________________, 20______
(Payor’s Name)
(Date to Credit Account)
The State of Nebraska will only accept non-monetary receipts for amounts which are equal-to or
less-than the amount owing on the credit date. If no amount is owing, no credit will or may be
given.
I understand that no credit will be given if there is a lien filed by any state agency or if I am
currently receiving ADC from the State.
The CLERK OF THE DISTRICT COURT accepts no responsibility for the content of this
notarized receipt. If you have any questions please contact your attorney.
________________________________________
__________________________________________
Print Your Name
Your Address
__________________________________________________________
City, State, Zip
_______________________________
Phone Number
_______________________________________________
Signature (Sign in the Presence of a Notary Public)
SUBSCRIBED AND SWORN TO BEFORE ME ON THIS ________DAY OF
__________________, 20_______
________________________________________________
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