STATE OF HAWAI221I FAMILY COURT FIRST CIRCUIT SUPPLEMENTAL AFFIDAVIT RE: DIRECT PAYMENT CHILD SUPPORT CASE NUMBER FC-D No. Plaintiff, v. Defendant. This document is prepared by:[ ] Attorney for [ ] Plaintiff [ ] Defendant Name Address City, State, Zip Code Telephone Number 1. My spouse and I have agreed that I shall pay child support directly to my spouse and not through the ChildSupport Enforcement Agency (CSEA). 2. Such an arrangement is in the best interest of our child(ren) because: 3. [ ] I affirm that all prior child support, ordered by the court [ ] I have not been previously ordered to pay or administratively, has been paid in a timely fashion. child support 4. Our child(ren) do/does not receive public assistance, welfare, foster care, Social Security, or other governmentalassistance. 5. There are no outstanding debts owed to the Department of Human Services or other public assistance agenciesby myself or my spouse. 6. I understand that at any time after the entry of our Divorce Decree, either party may void the direct paymentarrangement and apply for services from the CSEA to receive payment through the agency. 7. I further understand if our child(ren) receive(s) public assistance from the Department of Human Services, fostercare payments, or Social Security, or if either parent applies to the CSEA for services, CSEA may immediatelyvoid the direct payment arrangement by sending written notice by regular mail to both parents at their last knownaddresses as set forth in our Divorce Decree or subsequent child support order. 8. Based upon the facts set forth herein, I ask this Court to approve direct payments of child support rather thanrequiring that child support payments be made through the CSEA. I declare that I understand that my signature under oath before a notary public is my solemn statement thatI have read this affidavit and I know and understand the contents and that the statements are true, correct, and complete to the best of my knowledge. Date Signature (Sign with Notary Public present) Print Name: COURT USE ONLY Document Title: Supplemental Affidavit Re Direct Payment Child Support Document Date: No. of Pages: 1 was subscribed and sworn to before me in the First Circuit, State of Hawai221i by: Notary Public222s Signature: Date of Notary Public222s Signature: Print Notary Public222s Name: My commission expires: (Place Notary Seal Here) FC Adm 4/16/18 Supplemental Affidavit Re Direct Payment Child Support 1F-P-742 In accordance with the Americans with Disabilities Act, as amended, and other applicable state and federal laws, if you requireaccommodation for a disability, please contact the ADA Coordinator at the First Circuit Family Court office by telephone at954-8200, fax 954-8308, or via email at adarequest@courts.hawaii.gov at least ten (10) days prior to your hearing orappointment date. Please call the Family Court Service Center at 954-8290 if you have any questions about forms or procedures. American LegalNet, Inc. www.FormsWorkFlow.com