CASE NUMBER IN THE CIRCUIT COURT, EIGHTEENTH JUDICIAL CIRCUIT, BREVARD COUNTY, FLORIDA IN THE COUNTY COURT, BREVARD COUNTY, FLORIDA 05 - DIVISION CHILD SUPPORT - - - XXXX-XX BAR CODE LABEL VOLUNTARY/INCOME DEDUCTION AGREEMENT FOR CHILD SUPPORT/ALIMONY OBLIGATION CLOCK IN PETITIONER RESPONDENT I hereby authorize and direct my present and future employers to deduct $_______________ per _______________ from the w ages then due and ow ing to me, to be utilized for payment tow ard my child support alimony obligation. These sums are to be forw arded to: State of Florida Disbursement Unit (FLSDU) P.O. Box 8500 Tallahassee, FL 32314-8500 ASSIGNOR: EMPLOYER: ADDRESS: ADDRESS: CITY SSN#: ST ZIP CITY ST ZIP TELEPHONE NUMBER: Signature SWORN to and SUBSCRIBED before me this __________ day of ________________________________. NOTARY PUBLIC/DEPUTY CLERK LAW 258 Rev. 10/2005 ORIGINAL - COURT FILE COPY - OBLIGOR American LegalNet, Inc. www.FormsWorkflow.com