N ebraska State Court Form DC 3:03 NEW 09/18 Neb. Rev. Stat. 247247 42-1201- 42 - 1210, 29 - 4303 CONFIDENTIAL ADDRESS INFORMATION Page 1 of 1 Confidential Address Information DC 3:03 NEW 09/18 , Petitioner, vs. , Respondent, Case No. CONFIDENTIAL ADDRESS INFORMATION THIS INFORMATION IS CONFIDENTIAL I, , am the petitioner in the above-entitled action. I have received address protection from the Secretary of State pursuant to the Address Confidentiality Act (Neb. Rev. Stat. 247247 42-1201- 42-1210) I currently reside at a safe house, abuse shelter, or other facility that provided temporary emergency shelter and am bound by the limitation of disclosure as set forth in Neb. Rev. Stat. 247 29-4303(2). The address where the court may mail information regarding my case is listed below. I understand that the below information will be kept confidential by the court. Date Signature Name Street Address/P.O. Box City/State/ZIP Code Phone E-mail Address American LegalNet, Inc. www.FormsWorkFlow.com