CASE NUMBER IN THE CIRCUIT COURT, EIGHTEENTH JUDICIAL CIRCUIT, BREV ARD COUNTY, FLORIDA IN THE COUNTY COURT, BREV ARD COUNTY, FLORIDA DIVISION CIVIL CRIMINAL JUVENILE TRAFFIC 05 - - DR - - XXXX-XX BAR CODE LABEL PETITION TO CONTEST DELINQUENCY ACTION CLOCK IN OBLIGEE OBLIGOR Obligor date of birth: Obligor Social Security #: Obligor Driver's License #: I, , the obligor in the above referenced case, contest the delinquency action pursuant to 61.13016 F. S., on the ground of (check the box that applies) mistake of fact regarding the amount of a delinquency mistake of fact regarding the identity of the obligor The facts that support my motion are: (list the reason(s) why you contest the delinquency action) I certify that a copy of this Motion to Contest Delinquency Action was mailed to the obligee on and a copy was served on the Clerk of Court on Dated this day of , 20 , 20 . . Obligor' s Signature Address Address check if Address change Law 611 Rev. 10/2005 American LegalNet, Inc. www.USCourtForms.com