IN THE CIRCUIT COURT OF THE FIRST JUDICIAL CIRCUIT IN AND FOR SANTA ROSA COUNTY, FLORIDA , Case No.: Petitioner Division: and , Respondent ******************************************************************************************* DIRECT PAY AFFIDAVIT Before me the undersigned authority personally appeared ,who, being duly sworn, deposes and says: 1. That she/he is a child support/alimony payee by Court Order that requires the payor to make these payments through the designated depository. 2. Payee has received the following payments from the payor directly, in the amounts and on the dates set out below: Date Amount Date Amount For a total of $ Received for child support/alimony payments.3. That the payor is: (A) Current in his/her payments (Please initial if applicable) (B) In arrears in his/her payments in the amount of $ As of the payment due on the Day of , 20 .Further Affiant sayeth not. Signature of Payee Printed Name: Address: City, State, Zip: Telephone Number: ( ) Sworn to and subscribed before me this Day of , 20 . My Commission expires: Deputy Clerk/Notary Public