IN THE DISTRICT COURT OF DOUGLAS COUNTY, NEBRASKA vs Cl _ _ _ _ _ _ _ _ _ _ _ __ DOCKET_ _ _ _ _ PAGE _ _ __ Receipt is hereby acknowledged for _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Dated this_ _ _ _ _ day of _ _ _ _ _ _ ___, 20_ __ CURRENT E-MAIL ADDRESS PRINTED NAME CELL PHONE NUMBER SIGNATURE CURRENT ADDRESS **AMOUNTS RECEIPTED MAY AFFECT ELIBILITY FOR STATE BENEFITS. Subscribed and Sworn to before me this _ _ _ _ _day of _ _ _ _ _ _ _ 20_ _ NOTARY PUBLIC CLERK OF DISTRICT COURT WILL ONLY ACCEPT ORIGINAL NOTARIZED FORM American LegalNet, Inc. www.FormsWorkFlow.com