Note: an asterisk [ * ] indicates a required field.
The payee of the support order will be charged a small yearly fee once a certain amount of support has been disbursed. When a minimum of support has been disbursed, the next collection(s) will be kept by the Department and applied toward the fee. Once the fee has been paid collection(s) will be sent out. If the payee of the support order has more than one child support case, they will be charged a fee for each case. The payor of the support order will be given full credit for any payment(s) received.
Has a fee been assessed and collected in another state during the last year?
* If I receive support payments that I am not entitled to keep, or that were sent to me in error, I give the Department of Health and Human Services and/or the Nebraska Child Support Payment Center permission to recover these amounts from my future support payments.
* Do you believe that you and/or your children could be at serious risk of harm from the other parent?
Please include any additional information that may be helpful to Child Support Enforcement staff:
