IN THE DISTRICT COURT OF ___________________________ COUNTY, NEBRASKA (county where original action was filed) ________________________________, (name of person listed as plaintiff in original action) Plaintiff, vs. ________________________________, (name of person listed as defendant in original action) Case No. CI _____________ (case number assigned by Clerk of Court) CONFIDENTIAL PARTY INFORMATION Defendant. Plaintiff Name ______________________________________________________________________ (plaintiff's first, middle and last names) Address _____________________________________ Phone number _________________ (street, city, state, and zip code) (area code and phone number) Employer: __________________________________________________________________ (name and address of plaintiff's employer) Health insurance policy information (if provided through employer) ____________________________________________________________________________ (include name of company, policy number, address to submit claims, and whether insurance is available to minor children) Defendant Name ______________________________________________________________________ (defendant's first, middle and last names) Address _____________________________________ Phone number _________________ (street, city, state, and zip code) (area code and phone number) Employer: __________________________________________________________________ (name and address of defendant's employer) Health insurance policy information (if provided through employer) ______________________________________________ ______________________________________________ (include name of company, policy number, address to submit claims, and whether insurance is available to minor children) Person providing information:___________________________________ (your first, middle and last names) Date:________________ Confidential Party Information, DC 6:5(11) American LegalNet, Inc. www.FormsWorkFlow.com