IN THE DISTRICT COURT OF COUNTY, NEBRASKA (county where original action was filed) , (name of person listed as plaintiff in original action) Plaintiff, Case No. (case number assigned by lerk of ourt) vs. CONFIDENTIAL INFORMATION , (name of person listed as defendant in original action) Defendant. Name Plaintiff (plaintiff222s first, middle and last names) Address Phone number (street, city, state, and ZIP code) (area code and phone number) Employer: (name and address of plaintiff's employer) Health insurance policy information (if provided through employer) (include name of company, policy number, address to submit claims, and whether insurance is available to minor children) Defendant Name (defendant222s first, middle and last names) Address Phone number (street, city, state, and ZIP code) (area code and phone number) Employer: (name and address of defendant's employer) Health insurance policy information (if provided through employer) (include name of company, policy number, address to submit claims, and whether insurance is available to minor children) Date Signature Name Street Address/P.O. Box City/State/ZIP Code Phone E-mail Address American LegalNet, Inc. www.FormsWorkFlow.com