IN THE CIRCUIT COURT FOR THE THIRTEEN JUDICIAL CIRCUIT OF THE STATE OF FLORIDA, IN AND FOR HILLSBOROUGH COUNTY - FAMILY LAW DIVISION ______________________________________ Petitioner, Case No.: _________________________ Vs Division: _______________ _______________________________________ Respondent. AFFIDAVIT TO INITIATE PARTICIPATION IN THE CENTRAL GOVERNMENTAL DEPOSITORY PROGRAM BEFORE ME, the undersigned Notary Public, the undersigned personally appeared, who having being first duly sworn according to law deposes and says; 1. My, name is ____________________________________ and I am the in the above styled cause. Petitioner / Respondent 2. Pursuant to a court order entered on or after January 1, 1985, I am entitled to receive alimony and/or child support payments. 3. The court order did not require that the said alimony and/or child support payments be made through the Central Governmental Depository. 4. 5. Obligor/Payor has defaulted in his/her payments of alimony and/or child support and I hereby declare my wish to initiate participation in the Central Governmental Depository pursuant to: Alimony Florida Statute 61.08(4)(d)(2) or Child Support Florida Statute 61.13(1)(d)(2). One or both parties wish to initiate participation in the Central Governmental Depository Program. 6. I have provided the original of the affidavit , a completed Payment Information Sheet (Personal Information Form) along with a copy of the latest court order to Clerk of the Circuit Court, Family Law Division, Room 101, Edgecomb Civil Courthouse, 800 East Twiggs Street, Tampa, FL 33602 and have, by U.S. Mail, provided a copy of this affidavit to the other party at the following address: _________________________________________ _________________________________________ _________________________________________ FURTHER AFFIANT SAYETH NOT _______________________________________ AFFIANT (signature) STATE OF FLORIDA COUNTY OF HILLSBOROUGH The foregoing instrument was acknowledged before me this ____ day of _______________, 20_____, by (Seal) ________________________________________ Notary Public Signature / or Deputy Clerk ________________________________________ Personally Known _____ Printed Name Or produced identification _______ Type of Identification Produced ___________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Central Governmental Depository Personal Information Form Case Number : ____________________________ Date:_______________________ PI – OBLIGOR’S ADDRESS CHANGE PI – EMPLOYER UPDATE PI – OBLIGOR’S NAME CHANGE Comments: PI – OBLIGEE’S ADDRESS CHANGE PI – OBLIGEE’S NAME CHANGE ____________________________________________________________ ____________________________________________________________ OBLIGOR/RESPONDENT OBLIGEE/PETITIONER SSN: SSN: LAST NAME: LAST NAME: FIRST NAME: FIRST NAME: MIDDLE NAME: MIDDLE NAME: STREET ADDRESS: STREET ADDRESS: CITY, STATE ZIP: CITY, STATE ZIP: HOME PHONE: HOME PHONE: WORK PHONE: WORK PHONE: DATE OF BIRTH: DATE OF BIRTH: EMPLOYER: EMPLOYER: STREET ADDRESS: STREET ADDRESS: CITY, STATE ZIP: CITY, STATE ZIP: DRIVERS LICENSE #: DRIVERS LICENSE #: List Child(ren) Related to this Case: NAME: DATE OF BIRTH: NAME: DATE OF BIRTH: NAME: DATE OF BIRTH: NAME: DATE OF BIRTH: NAME: DATE OF BIRTH: NAME: DATE OF BIRTH: Signature: ____________________________________ Date: ______________________ American LegalNet, Inc. www.FormsWorkFlow.com