IN THE CIRCUIT COURT IN AND FOR ESCAMBIA COUNTY, FLORIDA FAMILY LAW DIVISION _____________________________, Petitioner Case Number: __________________ Division: ______________________ Vs. DEP ACCOUNT#:______________ _____________________________, Respondent AFFIDAVIT The undersigned, first being duly sworn, hereby states the following: 1. That he or she is the recipient of alimony/child support payments, which by court order are required to be made through the office of the Clerk of the Court. 2. That in addition to any payments received through the court depository, the payee has received the following payments from the payor directly in the amount and on the dates as set out below: DATE AMOUNT DATE AMOUNT ___________ ___________ ___________ ___________ ___________ ___________ $____________ $____________ $____________ $____________ $____________ $____________ ___________ ___________ ___________ ___________ ___________ ___________ $___________ $___________ $___________ $___________ $___________ $___________ for a total of $_____________ received in child support/alimony payments. Payee _____ waives, _____ does not waive interest due in the amount of $_________ as to Judgment/Certificate of Delinquency recorded in the Official Records Book ______, page_________ of the Public Records of Escambia County, Florida. 3. That the payor is ___ current in his or her payments, or ___ in arrears in the amount of $_______________ as of ____________________, 20____. 4. That I ____ am ____ am not currently receiving AFDC or other public assistance benefits from the State of Florida. 5. That although I may not be receiving AFDC or other public assistance benefits from the State of Florida at this time, that I ___ have ___ have not received such benefits at any time in the past. STATE OF FLORIDA ____________________________________ Petitioner/Payee COUNTY OF ESCAMBIA The foregoing instrument was acknowledged before me this ___ day of ______________, 20___, by _____________________, who is personally known to me or who has produced ___________________ as identification and who ___ did ___ did not take an oath. ____________________________________ NOTARY PUBLIC (SEAL) American LegalNet, Inc. www.FormsWorkflow.com IN THE CIRCUIT COURT IN AND FOR ESCAMBIA COUNTY, FLORIDA FAMILY LAW DIVISION _____________________________, Petitioner Case Number: __________________ Division: ______________________ Vs. DEP ACCOUNT#:______________ _____________________________, Respondent ORDER GIVING CREDIT FOR DIRECT PAYMENTS WHEREAS, it appears form the evidence submitted ____ through appropriate proof ____ by affidavit from the payee that the payor in the above cause has made child support and/or alimony payments directly to the payee and not through the court depository as previously ordered, and that the payment record in this case should be adjusted to reflect this/these direct payment(s) of support, it is therefore, ORDERED AND ADJUDGED: That the payee/recipient shall have fifteen (15) days from the date of this Order to submit a written request for a hearing as to whether credit is appropriate, and a hearing will be set. Absent a request for hearing, that credit shall be given for the sum of $____________ for direct payments to payee, and that the Clerk of the Court shall adjust their records to add this amount to records indicating payments made through the Central Depository. Payee has waived interest due in the amount of $________________. THE PARTIES are hereby notified that credit will not be given for any future payment(s) which are paid direct, and are further informed that all future payments shall be paid through the Central Governmental Depository unless otherwise ordered by the Court. DONE AND ORDERED at Pensacola, Escambia County, Florida this ____ day of ______________________, 20____. ____________________________________ CIRCUIT JUDGE I certify that a copy of the above Order was furnished to both parties at the following addresses this ____ day of ________________________, 20____. BY: ________________________________ Deputy Clerk (SEAL) Petitioner: Respondent: ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ American LegalNet, Inc. www.FormsWorkflow.com