IN THE CIRCUIT COURT FOR THE TWELFTH JUDICIAL CIRCUIT IN AND FOR MANATEE COUNTY, FLORIDA F AMILY DIVISION IN RE: CASE NO. ________________ ________________________________, Petitioner, and ________________________________, Respondent. ________________________ ___________/ MEMORANDUM TO CLERK TO: CLERK, CIRCUIT COURT, DOMESTIC RELATIONS DIVISION The Court has ordered the payment of child support and/or alimony to your office in the amounts and at the times indicated below. Please make disbursement of this money to the proper payee. PAYOR INFORMATION 1. Name: __________________ _______________________ Ho me Telephone: __________________ Address: ________________________ _____________________ _____________________________ ________________________ _____________________ ______________________________ ________ Date of Birth: _____________________ Social Security Number: _________________________ Drivers License Number: ______________________________ ______ State: ________________ Height: _________________ Sex: ___________ 2. Employer: ________________________ _____________________ ____________________________ Address: ________________________ _____________________ _____________________________ ________________________ _____________________ ______________________________ ________ Telephone: _________________ __________________ Wages: _____________________________ 3. Attorney for Payor:_____________________________________________________ _____________ PAYEE INFORMATION: >>>> 21. Name: __________________ _____________________ __ Home Telephone: ___________________ Address: ________________________ _____________________ ______________________________ ________________________ _____________________ ______________________________ _________ Social Secu: __________________________ Work Phone: rity Number _____________________ Date of Birth: ______________________ _____________ 2. Attorney for Payee:_____________________________________________ ____________________ 4. Children: N ame D ate of Birth S ocial Security Number ________________________ ______ __ ______ ______________ ______________________ __________________ ______________ ______ ______________ ______________________ __________________ ______________ ______ ______________ ______________________ __________________ ______________ ______ ______________ ______________________ __________________ ______________ ______ ______________ ______________________ __________________ ______________ ______ ______________ ______________________ PAYMENT INFORMATION: 1. Alimony Payable $_____ _______________ per _______________________ Current Child Support $____________________ per ________ _______________ Arrears Total $______________ ______ as of ______________________ Payable $______________ ______ per _______________________ Medical Total $______________ ______ as of ______________________ Payable $______________ ______ per _______________________ Medical Insurance Payable $_____ _______________ per _______________________ Attorney Fees/Costs $________ ____________ within _________________ days HLA Fees $_________________ ___ within _________________ days Clerks Fee $___________________ 2. TOTAL $_________________________ FIRST PAYMENT DUE ON:____________________ _______________ 3. Other: ________________________ _____________________ ______________________________ ________________________ _____________________ ______________________________ ________________________ _____________________ ______________________________ >>>> 3 ________________________ _____________________ ______________________________ ________________________ ____________ DATED ON THIS ___________ DAY OF _____________________, 20____. __________________________________ Signature