IN THE CIRCUIT COURT, EIGHTEENTH JUDICIAL CIRCUIT, BREVARD COUNTY, FLORIDA IN THE COUNTY COURT, BREVARD COUNTY, FLORIDA DIVISION CIVIL CRIMINAL JUVENILE TRAFFIC OBLIGEE CASE NUMBER 05 - - - - XXXX-XX BAR CODE LABEL REQUEST TO INITIATE SUSPENSION OF DELINQUENT OBLIGOR' S DRIVER' S LICENSE CLOCK IN OBLIGOR DOB: SS NUMBER: D/L NUMBER: I, , the Obligee in the above referenced case state that the above named obligor is delinquent in court ordered support payments. I request the Brevard County Clerk of Court initiate a driver' s license and motor vehicle registration suspension action against the above named obligor in accordance w ith the provisions of F.S. 61.13016(1). Dated this day of , 20 . Obligee' s Signature Street Address City/Sate/Zip Code Telephone Number NOTICE TO OBLIGEE: This suspension action may result in the suspension of the Obligor' s Driver' s License AND the suspension of the motor vehicle registration for vehicles registered in the Obligor' s name. LAW 539 Rev. 10/2005 American LegalNet, Inc. www.FormsWorkflow.com