Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 184 - NEBRASKA DEPARTMENT OF HEALTH
Chapter 2 - RULES OF PRACTICE AND PROCEDURE OF THE DEPARTMENT OF HEALTH FOR DECLARATORY ORDERS
Attachment 184-2-A
Current through March 20, 2024
BEFORE THE DEPARTMENT OF HEALTH STATE OF NEBRASKA
IN THE MATTER OF THE DECLARATORY ) SAMPLE
ORDER REQUEST OF _____name, ) PETITION FOR
Petitioner. ) DECLARATORY ORDER
COMES NOW the petitioner, _____(name)____, and under the authority of Neb. Rev. Stat. § 84-907.09 and 184 NAC 2, Rules of Practice and Procedure of the Department of Health for Declaratory Orders, requests that the Department of Health issue a declaratory order. In support of this request, the petitioner states the following:
1. That the Department of Health (Check as applicable):
() has promulgated ____ NAC ____, entitled ____________________
_______________________________________________________
() administers the provisions of Neb. Rev. Stat. §_____________, which states:
() in: ___(case)_____ issued an order dated _______ in ______ concerning the following:
2. That persons known to petitioner to have a specific personal interest in the applicability of the above statute/regulation/order and who is are or would be adversely affected by the uncertainty sought to be resolved by this request based upon the following facts include the following:
3. That consents to determining the issues in this petition by a declaratory order proceeding are attached:
4. That the question for which a declaratory order is sought is:
5. That a declaratory order on this question is requested based on the following factual situation:
6. That petitioner asks the Department to make a order finding that:
7. The reasons that the Department should rule as requested are:
_____
8. Petitioner requests opportunity to make an oral presentation on the petition.
DATED this _______day of ______________, 19___.
___________________________
Signature of Petitioner
STATE OF NEBRASKA )
) ss.
COUNTY OF ______ )
BEFORE KE personally appeared_____________, who, being first duly sworn, deposed and said that s/he is the petitioner or authorized representative of petitioner and that the facts submitted in this petition are true and complete.
(SEAL)
__________________
Notary Public
My commission expires____________________________________ *
TYPE OR PRINT:
_______________________________________________________
Full name
_______________________________________________________
Street Apt/Suite
_______________________________________________________
City State/Zip
Telephone: () _________________
REFER TO AND ATTACH ALL DOCUMENTS WHICH SUPPORT THE PETITION
