IN THE CIRCUIT COURT OF THE EIGHTH JUDICIAL CIRCUIT, IN AND FOR ALACHUA COUNTY, FLORIDA CASE NO. DIVISION Petitioner, and Respondent. AFFIDAVIT REGARDING DIRECT CHILD SUPPORT PAYMENTS I, hereby swear and/or affirm that I: received paid direct the following payments on the dates indicated: PAYMENT DATE PAYMENT AMOUNT , the Obligor Obligee, under penalty of perjury, do (you may need to add an attachment if you need more space than provided above) The total amount: received (as evidenced by copies of cancelled checks or receipts) paid (as evidenced by copies of cancelled checks or receipts) through direct payment is $ . American LegalNet, Inc. www.FormsWorkFlow.com I understand that I am swearing or affirming under oath to the truthfulness of the claims made above and that the punishment for knowingly making a false statement includes fines and/or imprisonment. Dated: Signature Printed Name: Address: City, State, Zip: Telephone Number: Fax Number: STATE OF FLORIDA COUNTY OF Sworn to or affirmed and signed before me on who is personally known OR produced identification . by NOTARY PUBLIC--STATE OF FLORIDA This form was completed with the assistance of: (Name of Individual) (Name of Business) (Address) (Telephone Number) American LegalNet, Inc. www.FormsWorkFlow.com