Request for Amount of Unpaid Support Owed To: Florida Office of Judges of Compensation Claims From: ____________________________________ ___________________ (Bar Number) I am requesting a written response as to the amount of unpaid child support the following individual owes, for the purpose of a workers' compensation claims settlement. This information will be used solely for that purpose and will not be otherwise disseminated or disclosed. I understand that the Clerk of Court is the official record keeper for child support. In accordance with Rule 60Q-6.123, the Office of Judges of Compensation Claims obtains information regarding unpaid child support from the Clerk of Court and Department of Revenue. OJCC Case Number: ______________________________________ Claimant Name: ________________________________________ Address: __________________________________ __________________________________ SS Number: ___________________________ Date of Birth: _____/______/_______ (mm/dd/yyyy) American LegalNet, Inc. www.FormsWorkFlow.com