Nebraska State Court Form AFFIDAVIT AND APPLICATION FOR PREPARATION OF REAL ESTATE ASSIGNMENT CERTIFICATE DC 6:4(7) NEW 01/18 Neb. Rev. Stat. § 42-372.02 IN THE DISTRICT COURT OF __________________ COUNTY, NEBRASKA (county where filed) ______________________________________, (your full name or the name of the plaintiff in the original action) Plaintiff, Case No. ____________________ vs. __________________________________, (other party's full name or the name of the defendant in the original action) AFFIDAVIT AND APPLICATION FOR PREPARATION OF REAL ESTATE ASSIGNMENT CERTIFICATE Defendant, ) ) ss: COUNTY OF_____________________) (county where signed) STATE OF NEBRASKA The undersigned, being first duly sworn on oath, deposes and says that: 1. I am the plaintiff/ defendant in the above entitled action and that I am of lawful age. 2. That this court entered a Decree of Dissolution of Marriage on _____________________, 20______, in which the interest of plaintiff/ defendant in the following described real estate in ____________________________ County, Nebraska, was assigned to __________________________________, Real Estate Description(s): plaintiff/ defendant, 3. I request the clerk of the district court of ______________________ County, Nebraska, pursuant to Neb. Rev. Stat. § 42-372.02 to prepare a Real Estate Assignment Certificate for the above named real estate description(s). The certificate may include more than one parcel of real estate, but a separate certificate for each party to whom real estate is assigned and a separate certificate for each county in which real estate is located is required and hereby requested. Page 1 of 2 Affidavit and Application for Preparation of Real Estate Assignment Certificate DC 6:4(7) NEW 01/18 American LegalNet, Inc. www.FormsWorkFlow.com 4. I understand that I, the plaintiff/ defendant, am responsible for recording the certificate or certificates with the register of deeds in the appropriate county or counties; and further that this certificate shall not be used in lieu of a deed or other conveyance of real estate to carry out the terms of the dissolution decree or as evidence of title. (Neb. Rev. Stat. § 76248.01) NOTICE: DO NOT SIGN UNTIL YOU ARE IN THE PRESENCE OF A NOTARY Date Signature Name Bar Number and Firm Name (attorneys only) Street Address/P.O. Box City/State/ZIP Code Phone E-mail Address SUBSCRIBED AND SWORN to before me this _______ day of _______________, 20_____. __________________________ Notary Public Page 2 of 2 Affidavit and Application for Preparation of Real Estate Assignment Certificate DC 6:4(7) NEW 01/18 American LegalNet, Inc. www.FormsWorkFlow.com