BANK ACCOUNT DEDUCTION REQUEST Please complete the following form so that we may execute a bank account automatic deduction for your Child Support Obligation. You MUST sign up for the amount you are court ordered to pay; If you erroneously sign up for too little, we will automatically modify this deduction request to meet your obligation amount. Date: Case Number: ABOUT YOU... Your Name: SS Number: Address: City: Zip Code: Phone Number: State: Date of Birth: ABOUT YOUR BANK... Bank Name: Account Number: Business Address: City: Zip Code: State: Business Phone Number: Branch: Checking or Savings (please circle) Deduction Cycle: (e.g. weekly, biweekly, monthly) ABOUT YOUR DEDUCTION REQUESTED... Court Ordered Obligation: Deduction Amount Requested: Please indicate the amount to be applied towards arrearages, if any: Do you wish for this to continue when arrearages are satisfied? Yes per per per No Should you be requesting an amount higher than your court ordered obligation which is NOT being applied to arrearages, please indicate below a brief statement of your intention for submitting this higher amount: SIGNATURE: I certify that the above information is true and correct CSEA-027 American LegalNet, Inc. www.USCourtForms.com