STATE OF FLORIDA DISBURSEMENT UNIT DIRECT DEPOSIT INFORMATION FORM NAME: _______________________________________________________________________ CASE NO: _____________________ SS # _____________________________________ ADDRESS ___________________________________________________________________ CITY ________________ COUNTY ________________ STATE ________ ZIP ___________ PHONE NUMBER _____________________________________________________________ I have authorized FL SDU To automatically Deposit my Child Support Payments at _____________________________________________________________ (Bank Name) (City) (State) Bank transit routing number: To the account selected below: Only one account can be selected for direct deposit of child support payments **Checking account number _________________________________________________ PLEASE ATTACH A VOIDED CHECK FOR THE CHECKING ACCOUNT. **Savings account number ________________________________________ PLEASE SUBMIT A LETTER FROM YOUR BANK THAT INCLUDES YOUR ACCOUNT NUMBER AND BANK ROUTING NUMBER. I understand that the full amount collected will be deposited. I also authorize the Bank to accept the deposit for my account and to make adjustments to my account that correct any error relating to the deposit. This authorization will remain in effect until revoked by me in writing or canceled by the Bank and supercedes any existing instructions concerning my child support direct deposit. I also understand that I have the responsibility for discontinuing the deposits. I agree that the Company will have no responsibility for personal checks written against my account, and that my account will be administered with the rules and regulations of the bank. Petitioner signature ____________________________________________________________________________ PLEASE MAIL FORM TO: Clerk of the Circuit Court, Hillsborough County Central Governmental Depository PO BOX 3450 Tampa, Florida 33601-3450 CGD102 (12-30-08) American LegalNet, Inc. www.FormsWorkFlow.com