SUPPORT INFORMATION SHEET PURSUANT TO S.61.13(10), F.S., THE SECOND PAGE OF THIS DOCUMENT, CONTAINING SOCIAL SECURITY NUMBERS OF THE PARTIES, SHALL BE KEPT CONFIDENTIAL FROM PUBLIC DISCLOSURE. THIS DOCUMENT IS NOT AN ORDER, AND IS FOR ADMINISTRATIVE USE BY THE CLERK. THIS DOCUMENT DOES NOT ESTABLISH OR MODIFY THE RIGHTS OFANY PARTY. THE FORMAT OF THIS DOCUMENT IS APPROVED BY ADMINISTRATIVE ORDER NUMBER 5.012/12-99, AND SHALL NOT BE AMENDED WITHOUT A NEW ADMINISTRATIVE ORDER. ___________________________and ___________________________CASE #_______________________DIV.__________ 9 1. DIRECT PAYMENT: All child support, alimony, or other support, included in any order requiring the payment of same shall be paid directly to:____________________________ (Name of person receiving support) address:___________________________________City/State/Zip:___________________ 9 2. 9 3. 9 4. PAYMENTS THROUGH THE COURT: All child support and/or alimony and/or arrearage will be paid to the Clerk of the Circuit Court. Payments should be sent to Family Division, Central Governmental Depository, P.O. Box 3597, West Palm Beach, Florida 33402-3597 together with the applicable service charge. PAYMENTS THROUGH STATE DISBURSEMENT UNIT: All child support and/or alimony and/or arrearage shall be made payable to and mailed to the State of Florida Disbursement Unit, Post Office Box 8500, Tallahassee, FL 32314-8500. CHILD SUPPORT: The following provisions for payment shall apply: 9 Temporary 9Permanent $_______________Total 9Modified (Child Support Payment) Child support payments shall start on ________________ (Date) and shall stop: 9 upon the child reaching the age of 18. 9 upon the child’s graduation from high school or at age 19. 9 upon the child’s graduation from college or at age ________. 9 by further order of Court or in accordance with the law. 9 5. ALIMONY: The following provisions for payment shall apply: $_______________Total (Alimony Payment) 9 TEMPORARY $_________________ 9 PERMANENT PERIODIC $_______ 9 REHABILITATIVE $_______________ 9 LUMP SUM $____________________ Payments shall start on ________________ and shall stop on ________________ or upon full payment. (Date) (Date) 9 6. ARREARAGE $_______________DUE AS OF ___________________. $_______________Total (Arrearage Payment) Arrearage payments shall start on _______________ in the amount of $__________ and shall stop upon full payment. (Date) 9 7. OTHER PAYMENTS: DUE FOR ___________________________________ $_______________Total (equitable distribution, attorney’ fees, etc) s Payments shall start on _______________ in the amount of $__________ and shall stop upon full payment. (Date) 9 8. SERVICE CHARGE: 4% of each payment, not to exceed $5.25: 9. PAYMENT SCHEDULE : Payment shall be made: 9 WEEKLY 9 EVERY OTHER WEEK 9 MONTHLY 9 TWICE MONTHLY 9 (1ST & 15TH) $_________________Total $___________________ GRAND TOTAL (Add Child Support, Alimony, 9 (15TH & 30TH) Arrearage or other payment) 1 2000 © American LegalNet, Inc. ******CLERK: PLEASE KEEP THIS PAGE SEPARATE FROM FILE AND KEEP CONFIDENTIAL****** 10. PERSONAL INFORMATION: Person Paying Support (Obligor) Person Receiving Support (Obligee) Name:___________________________________ Name:______________________________________ Address:_________________________________ Address:____________________________________ City/State/Zip:____________________________ City/State/Zip:_______________________________ Phone Number:(____)______________________ Phone Number:(_____)________________________ Driver's License No.:_____-_____-_____-______ Driver's License No.:_____-_____-_____-_________ Car Tag Number:__________________________ Car Tag Number:_____________________________ Date of Birth:__________/__________/________ Date of Birth:__________/__________/___________ Social Security Number:_______-______-______ Social Security Number:________-______-________ Employer:___________________________________ Employer:___________________________________ Employer Address:____________________________ Employer Address:____________________________ ___________________________________________ ___________________________________________ Employer's Phone Number (____)______________ Employer's Phone Number (____)______________ Children: Name:__________________________________DOB:__________/__________/__________SS No.:_____-______-_______ Name:__________________________________DOB:__________/__________/__________SS No.:_____-______-_______ Name:__________________________________DOB:__________/__________/__________SS No.:_____-______-_______ Name:__________________________________DOB:__________/__________/__________SS No.:_____-______-_______ PREPARED BY: ____________________________________ Name REVIEWED BY: ____________________________________ Name _____________________________ Date _____________________________ Date 2 2000 © American LegalNet, Inc. sis2/12-16-99/lrs 3 2000 © American LegalNet, Inc.