IN THE CIRCUIT COURT OF THE THIRTEENTH JUDICIAL CIRCUIT, IN AND FOR HILLSBOROUGH COUNTY, FLORIDA _____________________________ PAYEE CASE NUMBER: ____________________ Vs USN NUMBER: _____________________ _____________________________ PAYOR Payor Name: ____________________________ Date of Birth: ___________________________ Social Security Number: ___________________ Driver’s License: _________________________ State: __________________________________ REQUEST TO SUSPEND DRIVER’S LICENSE AND MOTOR VEHICLE REGISTRATION I, __________________________ hereby request the depository to initiate driver’s license suspension action against the above named Payor in accordance with the provisions of F.S.61.13016. To the best of my knowledge, the Payor’s current address is: ______________________________________________________ ______________________________________________________ ______________________________________________________ DATED this __________ day of __________________, 20_____. ______________________________ Payee’s Signature American LegalNet, Inc. www.FormsWorkflow.com