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NEBRASKA THOROUGHBRED BREEDER'S ASS'N.
PO Box 2215 - Grand Island, NE 68802


_______________________________________
(Name of Foal registered Nebr. Bred)
(Nebraska Bred Class____________)

BREEDERS CERTIFICATE
I hereby certify that the (Color)_________(sex)______________(Name)__________________________
By______________________________________out of ________________________________________
Jockey Club Registration No. _____________________was foaled ______________________________
at (Town)________________, (State) _______
I further certify that at the time the above named Foal was dropped, the dam,
_________________________________, was owned by_______________________________________
(Town)___________________________, (State)_________________
and was registered with the Nebraska Thoroughbred Breeder's Association and the Nebraska State Racing Commission as required by the rules governing the qualification of "Nebraska Bred" foals.
Signed __________________________________

IMPORTANT

Owner of Dam (Breeder)
The name, address and zip number should be complete as it will be used as the address for mailing of Breeder's Award checks ________________________________

Street or RFD Number
________________________________

City, State, Zip
State of Nebraska ) ss
County                )
On this _____ day of ___________ A.D. ______ before me a Notary Public in and for said County, personally came the above named ___________________________ who is personally known to me to be the identical person, whose name is hereto affixed and acknowledged said instrument to be signed voluntarily.

(Seal)

(Notary Public)
My commission expires on the ___________ day of _________________A.D. ________________
Date: _______________

The above affidavit has been verified and the classification is Nebraska-Bred

Class: _______________

NEBRASKA THOROUGHBRED BREEDER'S ASSOCIATION

By:_______________________________________
NOTE: This Certificate and all copies must be filled in completely and signed before a Notary Public whose Seal must be affixed. When completed, it must be presented to the office of the Nebraska Thoroughbred Breeder's Association for verification and classification. It will then be filed with the Nebraska State Racing Commmison.