DC 6:2 Rev 10/16 IN THE DISTRICT COURT OF COUNTY, NEBRASKA Plaintiff vs. Defendant CASE APPLICATION AND AFFIDAVIT FOR TERMINATION OF CHILD SUPPORT I, , swear that the child, , for whom I am currently ordered to pay child support is no longer my obligation for the following reason: The child is now 19 years old. Certified copy of irth ertificate attached.** The child has married. Certified copy of marriage license and certificate of marriage attached.** The child has died. Certified copy of death certificate attached. ** The child has been emancipated by court order from Certified copy of the court order attached I request that my child support obligation for the above child be terminated on . I request that the clerk of court send a copy of this application, not including Appendix 3 if received by the court, to the last known address of the adult who is receiving child support on behalf of my child, unless accompanied Name of adult Street address City, State, Zip Page 1 of 2.Child Support Termination Application and Affidavit DC 6:2 Rev. 10/16 American LegalNet, Inc. www.FormsWorkFlow.com I understand that if there is any unpaid child support or interest owed prior to the requested date of termination, that amount is still owed. In the event the adult receiving support for the child does not file an objection within thirty days after the clerk222s notice to him/her was mailed, I hereby request that the child support for the above child be terminated by court order as requested. SIGN IN FRONT OF NOTARY PUBLIC I hereby swear, or affirm, under penalty of perjury, that the above information is true. Date Signature Your Full Name (person paying support) Your Full Street Address/P.O. Box City/State/ZIP Code Phone E-mail Address State of ) ) ss. County of ) The foregoing instrument was acknowledged before me by , this (ame of person certifying above) day of , 20 . ay onth ear Notary Public (signature of person taking acknowledgment) My commission expires: (title or rank) (serial number, if any) CLERK'S SERVICE OF NOTICE ON RECEIVER AND ASSIGNEE A true and accurate copy of this application and affidavit to obtain termination of child support was sent by the lerk of the istrict ourt to: 1. The person receiving child support at the above address, and 2. The Department of Health and Human Services if there is an active assignment of support, by depositing copies thereof in the U.S. mail, postage prepaid on this day of, 20 . NOTICE TO RECEIVER OF CHILD SUPPORT The court shall terminate child support if no written objection has been filed within thirty days after the date the clerk's notice to the receiver was mailed, the forms and procedures have been complied with, and the court believes that a hearing on the matter is not required. As receiver of child support, if you do not file a written objection within thirty days after the date the notice was mailed, child support for this child may be terminated without further notice to you. Page 2 of 2 Child Support Termination Application and Affidavit DC 6:2 Rev. 10/16 American LegalNet, Inc. www.FormsWorkFlow.com