(county where original action was filed)

THIS DOCUMENT IS CONFIDENTIAL AND SHALL NOT BE MADE PART OF THE CASE FILE OR PROVIDED TO THE PUBLIC

Case No. CI ____________ (case number assigned by Clerk of Court)

SOCIAL SECURITY NUMBERS, GENDER, AND BIRTH DATE(S)

vs.

________________________________________, (name of person listed as defendant/respondent in original action)

Defendant/Respondent.

Names Social Security Number Gender Date of Birth

Plaintiff /Petitioner:

__________________ ____________________ _______ _____________

Defendant/Respondent:

____________________ _______ _____________ ___________________

Additional Petitioner(s)/Minor Children:

___________________ ____________________ _______ _____________

___________________ ____________________ _______ _____________

___________________ ____________________ _______ _____________

___________________ ____________________ _______ _____________

___________________ ____________________ _______ _____________

Nebraska State Court Form

DC 6:5.12 Rev. 06/19 Neb. Ct. R. § 6-1521

SOCIAL SECURITY NUMBERS, GENDER, AND BIRTH DATE(S)

(For other information, add pages as required.)

Page 1 of 1Social Security, Gender, Birth Date DC 6:5.12 Rev. 06/19PSC Nebraska

o/b/o OR Additional Petitioner/Minor Child(ren) ,

Additional Petitioner/Minor Child(ren),

________________________________________, (name of person listed as plaintiff/petitioner in original action)

Plaintiff/Petitioner, If you are filing for a protection order, fill in the next two lines the same way that they are listed on the petition