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Nebraska Confidential Party Information Form

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Nebraska Confidential Party Information Form
Nebraska Confidential Party Information Form
Confidential Party Information, DC 6:5(11), PSC Nebraska.
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. CI _____________
(case number assigned by Clerk of Court)
vs.
CONFIDENTIAL
PARTY INFORMATION
________________________________,
(name of person listed as defendant in original action)
Defendant.
Name ______________________________________________________________________
Plaintiff
(plaintiff’s 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)
Name ______________________________________________________________________
Defendant
(defendant’s 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)
Person providing
information:___________________________________
(your first, middle and last names)
Date:________________
Nebraska Confidential Party Information Form