Nebraska State Court Form AFFIDAVIT AND APPLICATION FOR ORDER TO SHOW CAUSE (Support) DC 6:5(20) Rev. 04/15 IN THE DISTRICT COURT OF ____________________ COUNTY, NEBRASKA (county where original action filed) ________________________________, (name of person listed as plaintiff in original action) Plaintiff, vs. Case No. CI __________________ (case number assigned by Clerk of Court) ________________________________, (name of person listed as defendant in original action) AFFIDAVIT AND APPLICATION FOR ORDER TO SHOW CAUSE (Support) Defendant. I ___________________________________, without assistance of an attorney, (your name) ask this Court for an order requiring ____________________________________ to (name of person ordered to pay support) show cause why he/she should not be held in contempt for failing to pay child support as ordered. In support of my Application, I state that the following items are true: 1. On ___________________________________, an order was entered requiring (date Judge signed order for support) ___________________________________________ to pay: (name of person ordered to pay support) Check all that apply: [ ] child support of ___________________ per month beginning (amount of monthly child support ordered) ___________________________________. (date child support ordered to begin) [ [ Page 1 of 3 ] child-care expenses. ] health-related expenses. Affidavit and Application for Order to Show Cause (Support) DC 6:5(20) Rev. 04/15 American LegalNet, Inc. www.FormsWorkFlow.com 2. The above order is still in effect. 3. Check all that apply: [ ] ____________________________________________ is more than (name of person ordered to pay child support) one month behind in the payment of child support. As of ___________________________, _____________________________ (date child support delinquency computed) (name of person ordered to pay child support) owes a total of ______________________ child support. (amount of support owed) [ ] __________________________________________ is more than (name of person ordered to pay health-care expenses) one month behind in the payment of health-care expenses. As of ___________________________, _____________________________ (date health-care expense delinquency computed) (name of person ordered to pay health-care expenses) owes a total of ______________________ health-care expenses. (amount of health-care expenses owed) [ ] ____________________________________________ is more than (name of person ordered to pay child-care expenses) one month behind in the payment of child-care expenses. As of ___________________________, _____________________________ (date child-care expense delinquency computed) (name of person ordered to pay child-care expense) owes a total of ______________________ child-care expense. (amount of child-care expenses owed) 4. ______________________________'s failure to pay as ordered is willful. (name of person ordered to pay) WHEREFORE, I request the court issue an Order directing ____________________________________ to appear before this Court on a specific (name of person ordered to pay child support) day and at a specific time to show cause why he/she should not be held in contempt for failing to pay child support, child-care expenses, or health-care expenses as ordered by Page 2 of 3 Affidavit and Application for Order to Show Cause (Support) DC 6:5(20) Rev. 04/15 American LegalNet, Inc. www.FormsWorkFlow.com the court. I further request that _________________________________ be ordered to (name of person ordered to pay child support) pay the expenses of this action and for any further relief that may be just. Date Your Signature Your Full Name Your Full Street Address/P.O. Box City/State/ZIP Code Phone E-mail Address VERIFICATION STATE OF NEBRASKA COUNTY OF ___________________ (county where notarized) ) ) ) ss I, _______________________________, first being sworn upon oath, depose and say that I am a party in the above-entitled matter and have read the foregoing Affid Affidavit and Application for Order to Show Cause and state that the facts contained therein are true. The foregoing instrument was acknowledged before me by (Name of person certifying above) (your full name) , this day of Day (title or rank) Month , Year . Notary Public (signature of person taking acknowledgment) My commission expires: (serial number, if any) Page 3 of 3 Affidavit and Application for Order to Show Cause (Support) DC 6:5(20) Rev. 04/15 American LegalNet, Inc. www.FormsWorkFlow.com