Child Support Depository P.O. Box 25400, 1115 Manatee Ave W, Bradenton, FL 34206 (941) 741-4038 Date: _____________________ State of Florida Dept of Labor & Employment Security Office of the Judges of Compensation Claims 6497 Parkland Drive, Suite M Sarasota, FL 34243 Employee-Claimant: ___________________________________________ ___________________________________________ ___________________________________________ Requested by: __________________________________________ __________________________________________ __________________________________________ __________________________________________ Carrier: __________________________________________ __________________________________________ __________________________________________ Social Security #___________________________ Date of Birth ______________________________ RE: WORKERS’ COMPENSATION CLAIMS/DELINQUENT CHILD SUPPORT CASE NON-CUSTODIAL PARENT: ________________________________________SS#___________________________________ CUSTODIAL PARENT: _____________________________________________SS#____________________________________ Dear Honorable ___________________: _____ The records of the Central Depository indicate an active account, case # ______________________________ for the aforementioned parties. As of ______________________, an arrearage of _________________________ exists, pursuant to the attached certified affidavit. _____ The records of the Central Depository do not reflect any account for the aforementioned parties as of ____________________. Sincerely, R. B. “Chips” Shore Clerk of Circuit Court By: ________________________________________ Deputy Clerk __________________________________________ Clerk’s Seal The State IV-D database indicates there is ____ is not ____ an order for support in _____________________ County. ____________________________________ Signature and Title American LegalNet, Inc. www.USCourtForms.com