CASE NUMBER IN THE CIRCUIT COURT, EIGHTEENTH JUDICIAL CIRCUIT, BREVARD COUNTY, FLORIDA 05 - APPLICATION TO DIRECT PAYMENTS THROUGH THE DEPOSITORY - - XXXX-XX - CLOCK IN PAYEE PAYOR PAYOR S.S# PAYEE S.S# ADDRESS: ADDRESS: P.O. BOX P.O. BOX CITY ST ZIP CITY Before me personally appeared ST ZIP , who after being duly sworn, states: Pursuant to Sec. 61.13(1)(d)4 F.S., makes application to require all future court ordered payments to be made through the State of Florida Disbursement Unit. Pursuant to Sec. 61.13(1)(d)4 F.S., the payor has defaulted in payment and the payee wishes to require the payments be made through the State of Florida Disbursement Unit. The current arrearage is $ , with the next payment of $ due on . The payor is in default of payment. I hereby certify that the above noted arrearage is correct. WHEREFORE, the payee requests that future child support and/or alimony payments be directed through the Brevard County Child Support Division and that the proper notice be mailed to both parties in compliance with Chapter 61, F.S. Affiant's Signature Date SWORN TO AND SUBSCRIBED BEFORE ME this day of , 20 . By: Deputy Clerk/Notary Public I hereby certify that a copy of the foregoing application was mailed to: MITCH NEEDELMAN CLERK OF THE COURT Law 260 Rev. 01/03/2011 DATE BY DC BAR CODE LABEL American LegalNet, Inc. www.FormsWorkFlow.com