CLERK OF THE CIRCUIT COURT AND COMPTROLLER CHILD SUPPORT ENFORCEMENT Date: _______________________________ Requested by: State of Florida __________________________ Division of Administrative Hearings __________________________ Office of the Judges of __________________________ Compensation Claims __________________________ [district address] Employee/Claimant:___________________ Carrier:__________________ __________________________________ __________________________ __________________________________ __________________________ Social Security No.: ________________ Date of Birth: ________________ RE: WORKERS COMPENSATION CLAIMS/DELINQUENT CHILD SUPPORT CASE Non-custodial parent:___________________________________________ Social Security No.: ________________ Custodial parent: ___________________________________________ Social Security No.: ________________ Dear Judge __________________________: _____ The records of the Central Depository indicate an active account, Case No. ________________, for the above parties. As of ____________________, an arrearage of $____________ exists, pursuant to the attached certified affidavit. _____ The records of the Central Depository do not reflect an account for the above parties as of _____________________. Sincerely, By: ____________________________________ Department of Revenue Representative 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