92 Neb. Admin. Code, ch. 64, Attachment 4

BEFORE THE STATE DEPARTMENT OF EDUCATION STATE OF NEBRASKA

In the matter of the Negotiated ) Certification of

Rulemaking Committee for ) Financial

[Insert name of the proposed ) Need

Negotiated Rulemaking Committee], )

____ 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 State Department of Education.

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 the Department in order to serve.

_________________________________________________________

Signature of Affiant

Subscribed and sworn to before me this ______ day of ___________, 19 ______ .

________________________________

Notary Public

Notes

92 Neb. Admin. Code, ch. 64, Attachment 4