Nebraska State Court Form REQUIRED DENIAL OF INTRASTATE TRANSFER AND CERTIFICATE OF MAILING CC 16:2.125 New 10/2015 Page 1 of IN THE COUNTY COURT OF COUNTY, NEBRASKA IN THE MATTER OF Ward/Incapacitated Person/Protected Person Case DENIAL OF INTRASTATE TRANSFER AND CERTIFICATE OF MAILING This matter comes before the court upon receipt of a provisional order for transfer of this guardianship/conservatorship from County Court to County Court. This ourt hDATED . BY THE COURT: County Judge American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 CERTIFICATE OF MAILING I certify that on , I mailed a copy of this order to the originating court and to all interested persons listed below: NAME(S) OF INTERESTED PERSON(S) ADDRESS(ES) See attached (more names and addresses than above) American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3 *Interested persons are defined as:children and spouses;future heirs if the ward/incapacitated person/protected person would die without leaving avalid will (brothers and sisters who are adults, grandparents, etc.);a trustee of any trust executed by the ward/incapacitated person/protected person;if there are no individuals defined as 223interested persons224 above, include any person ororganization named as a 223devisee224 in the ward222s/incapacitated person222s/protected person222smost recent will;after death of the ward/incapacitated person/protected person, interested person alsoincludes the personal representative of a deceased ward222s/incapacitated person222s/protectedperson222s estate, the deceased ward222s/incapacitated person222s/protected person222s heirs in anintestate estate, and the deceased ward222s/incapacitated person222s/protected person222s deviseesin a testate estate;any governmental agency paying benefits on behalf of the ward/incapacitatedperson/protected person; andany person designated by order of the court to be an interested person. If there are no interested persons identified for a ward/incapacitated person/protected person, the court shall appoint a guardian ad litem (Nebraska Supreme Court Rule 247 6-1449(B)). The cost of the guardian ad litem may be taken from the assets of the ward/incapacitated person/protected person. American LegalNet, Inc. www.FormsWorkFlow.com