IN THE CIRCUIT COURT, OF THE FOURTH JUDICIAL CIRCUIT, IN AND FOR CLAY COUNTY, FLORIDA. PAYEE CASE NO.: VS. DIVISION: PAYOR Date of Birth: Drivers License #: REQUEST TO SUSPEND DRIVERS LICE NSE AND MOTOR VEHICLE REGISTRATION I, hereby request the Central Governmental Depository to initiate drivers license suspension action against the above name d Payor in accordance with the provisions of F.S. 61.13016 and 322.058. To the best of my knowledge, the Payors current address is: DATED this day of , 20 . Payees Signature Payees Address: City/State/Zip CC: New Address: Yes No ____________________________________ appeared before me and acknowledged that he/she signed the foregoing this _________________ day of __________________________, 20______. ________________________________________Notary Public, State of Florida or Deputy Clerk Seal R Check one only: Personally known Produced identification Type of identification produced_________________________________________ _