IN THE ________ JUDICIAL CIRCUIT COURT, _______________________, MISSOURI Judge or Division: Case Number: MACSS Case ID: Petitioner’s Address: Petitioner: SSN (last four digits): vs. Respondent: Respondent’s Address: SSN (last four digits): (Date File Stamp) Acknowledgment Agreeing to Termination of Child Support NOTE: This form may be used only where a claim is made that no child remains entitled to support. Directions: If you are the person receiving support and you agree to termination of the obligation to pay support for the child, you may, but are not required to, file this Acknowledgment with the Court. (See Certificate of Person Receiving Support below.) Upon your filing of this Acknowledgment, a judgment terminating the obligation to pay support for the child will be entered. Your failure to file this Acknowledgment within 30 days of your receipt of the Affidavit may result in entry by default of a judgment terminating the obligation to pay support for the child. I, ______________________________, am receiving support for _________________________________ (name) (hereinafter referred to as the child), whose age is _____________________. I acknowledge that the child is no longer entitled to support and, therefore, agree to termination of the obligation of ______________________________ (name) to pay support for the child. The facts in this Acknowledgment are true to my best knowledge and belief and are made under penalty of perjury. ______________________________________ Signature of Person Receiving Support __________________________ Date Certificate of Person Receiving Support I certify that on __________________ (date), I filed the original of this Acknowledgment with the Circuit Clerk of _____________________________ (County/City of St. Louis), Missouri, at _____________________________________ (address) and mailed a copy of this Acknowledgment to ______________________________________ (name), the person paying support, at ___________________________________ (address), _____________________________ (city), ________________ (state). ______________________________________ Signature of Person Receiving Support OSCA (8-09) CS96 1 of 1 452.340 RSMo American LegalNet, Inc. www.FormsWorkFlow.com