IN THE DISTRICT COURT OF DOUGLAS COUNTY, NEBRASKA __________________________ Plaintiff vs. __________________________ Defendant ) ) ) ) ) ) ) ) ) ) Docket______ Page______ AFFIDAVIT (Payor) (RE: Child Support Credit) ____________________, being first duly sworn upon oath deposes and states that: (Affiant) 1. 2. As Affiant, it is stated in my Decree or Court order, that Child Support I further swear that every attempt has been made by me to obtain a receipt I do hearby swear is abated or reduced if I have the child(children) for visitation. of satisfaction from _________________________, to verify my months of visitation and that these attempts have been unsuccessful. that I did have visitation for the month(s) and year(s) listed below and do request that credit be given to me for Child Support for the following: _______________________________ Exact days of visitation ________________________________________ Dollar amount to be credited as stated per decree or court order for visitation Affiant further swears that I realize that this affidavit is a binding legal document and that I, Affiant, request for the credit of the above listed amounts of child support to be reflected in the child support to off set the accrued due for the month(s) and year(s) listed above. Affiant also understands that no credit in excess of that which is stated in the decree or order can be given by the Clerk of the District Courts office. FURTHER AFFIANT SAITH NAUGHT, ______________________________________ Affiant Subscribed and sworn before me this day of__ , 20___. ________ NOTARY PUBLIC _____ CLERK OF THE DISTRICT COURT WILL ONLY ACCEPT ORIGINAL NOTARIZED FORM. American LegalNet, Inc. www.FormsWorkFlow.com Prtra51: 05/07