163 Neb. Admin. Code, ch. 1, Attachment 4

Current through September 17, 2024

Attachment 163-1-4

BEFORE THE Game and Parks Commission STATE OF NEBRASKA

In the matter of the Negotiated) Certification of

Rulemaking Committee for) Financial

[Insert name of the proposed) Need

Negotiated Rulemaking Committee],)

163 NAC _____.

STATE OF NEBRASKA)

) ss.

COUNTY OF _)

COMES NOW the undersigned, being first duly sworn, and hereby states and certifies as follows:

1. I am a member of the above-referenced Negotiated Rulemaking Committee created by the Game and Parks Commission.

2. In connection with my duties on that committee, I represent [insert the name of the appropriate identified interest].

3. In connection with my duties on that committee, I have incurred or will incur expenses and/or other costs.

4. I certify that I have a lack of adequate financial resources to serve on the above-referenced Negotiated Rulemaking Committee, and that I need financial assistance from this Commission in order to serve.

__________________________________

Signature of Affiant

Subscribed and sworn to before me this ________ day of ________, 2_______.

________________________

Notary Public

163 Neb. Admin. Code, ch. 1, Attachment 4