IN THE CIRCUIT COURT IN THE EIGHTEENTH JUDICIAL CIRCUIT IN AND FOR BREVARD COUNTY, FLORIDA. Case No.: ___________________________________, Petitioner Bar Code Label and , Respondent ORDER REQUIRING PAYMENT THROUGH CENTRAL DEPOSITORY [v check all which apply, fill in all blanks that apply] IT IS ORDERED AND ADJUDGED that all payments of child support shall be as follows: [ ] Obligor will make the payments ordered – Fill out A & B below, NOT C. [ ] Payment will be by income deduction order and payor is not the obligor – Fill out A, B, & C. A. PAYOR INFORMATION 1. Name:________________________________________ DOB:______________________ Social Security Number:__________________________ Phone:____________________ Street:___________________________________________________________________ City:____________________________ State:____________________ Zip:___________ Employer:______________________________________ Phone:____________________ Street:___________________________________________________________________ City:____________________________ State:____________________ Zip:___________ Other sources of income:____________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ B. PAYEE INFORMATION 1. Name:________________________________________ DOB:_____________________ Social Security Number:__________________________ Phone:____________________ Street:___________________________________________________________________ City:____________________________ State:____________________ Zip:___________ Law 1086– Rev . 10/2005 1 American LegalNet, Inc. www.FormsWorkflow.com Order Requiring Payment Through Central Depository Page 2 2. Children for whom support is to be paid: Name ________________________ ________________________ ________________________ ________________________ C. Case No:____________________________ Date of Birth __________ __________ __________ __________ Age ___ ___ ___ ___ Sex ___ ___ ___ ___ Social Security No. _________________ _________________ _________________ _________________ PAYOR INFORMATION (fill out only if payor is NOT obligor) Name (obligor’s employer):________________________________________________________ Named agent for service:___________________________________________________________ Street:_________________________________________________________________________ City:______________________________ State:_______________________ Zip:_________ Telephone:_________________________ Telefax:_____________________ D. MANNER AND METHOD OF PAYMENT [v check all which apply, fill in all blanks that apply] 1. Regular Child Support [v one only] [ ] The payor shall pay the sum of $_______________ per ____________ for ________ children, plus the Clerk’s processing fee as set forth in paragraph 8 below. [ ] The payor shall pay the sum of $_______________ per ____________ for ________ children, from which the Clerk shall deduct its processing fee. 2. Past Due Child Support/Arreages [ ] The payor shall pay the sum of $_______________ per ____________ for ________ children, and the Clerk’s processing fee for past due child support. This payment for past due child support shall last for ________ [ ] months [ ] years, until all past due support, fees to the Central Depository and interest are paid. Interest on past due child support shall be added obligor’s debt at the rate of ________% per annum until paid. 3. Alimony [v one only] [ ] The payor shall pay the sum of $_______________ per ____________ for alimony, plus the Clerk’s processing fee as set forth in paragraph 8 below. Law 1086– Rev . 10/2005 2 American LegalNet, Inc. www.FormsWorkflow.com Order Requiring Payment Through Central Depository Page 3 Case No:____________________________ [ ] The payor shall pay the sum of $_______________ per ____________ for alimony, from which the Clerk shall deduct the processing fee. 4. Past Due Alimony/Arrearages [v one only] [ ] The payor shall pay the sum of $_______________ per ____________, plus the Clerk’s processing fee for past due alimony. This payment for past due alimony shall last for ________ months until all past due alimony is paid. 5. Payments shall begin on the date of entry of this order and payments shall continue to be made the way this order says they will be paid and in the amount this order says will be paid unless and until this Court orders something else. 6. Payments shall be sent to: STATE OF FLORIDA DISBURSEMENT UNIT P. O. Box 8500 Tallahassee, Florida 32314-8500 877-769-0251 7. Payment shall be made by check or money order. For identification and accounting purposes, you must write the court case number, social security number, and county where the court order is located (Brevard), on each payment made by check or money order and be attached on a separate sheet of paper with any case payment. If payment is made by check, the Clerk may require a payor to fill out a form. 8. Any depository processing fees as allowed in section 61.181, Florida Statutes, shall be paid with each payment. The amount of the service fee is 4% of the total payment, but not less than $1.25 and not more than $5.25. 9. The parties affected by this order must tell the central depository right away if there is any change of name, address, employer, place of employment, or source of income. DONE AND ORDERED in Brevard County, Florida on {date}_____________________, 20___. _____________________________________ Circuit Judge Law 1086– Rev . 10/2005 3 American LegalNet, Inc. www.FormsWorkflow.com Order Requiring Payment Through Central Depository Page 4 Case No:____________________________ Cc: Petitioner or their attorney (if represented) Name_____________________________ Address___________________________ _________________________________ City State Zip Respondent or their attorney (if represented) Name________________________________ Address______________________________ _____________________________________ City State Zip Other Name_____________________________ Address___________________________ _________________________________ City State Zip Law 1086– Rev . 10/2005 4 American LegalNet, Inc. www.FormsWorkflow.com