IN THE NEBRASKA WORKERS' COMPENSATION COURT THIS DOCUMENT IS CONFIDENTIAL AND SHALL NOT BE MADE PART OF THE COURT FILE OR PROVIDED TO THE PUBLIC PURSUANT TO WORKERS' COMP. CT. R. OF PROC. 2. __________________________________, Plaintiff, ) ) ) ) ) ) ) ) ) ) DOC: NO:
PERSONAL AND FINANCIAL ACCOUNT INFORMATION
vs. __________________________________, Defendant.
Employee Social Security Number Employee Date of Birth (if applicable to this case)
___________________ ___________________
Minor Children (if applicable to this case) Name __________________ __________________ __________________ Social Security Number _____________________ _____________________ _____________________ Date of Birth ___________ ___________ ___________
Protected financial account information (if applicable to this case) Entity/Person Type of Account Account Number
________________
__________________
___________________
(add additional pages as necessary)
Addendum 3