MC: ME Bar Code Area FS#: Central File Maintenance P.O. BOX 12048 AUSTIN, TX 78711-2048 Affidavit of Direct payment letter Date: Dear Custodial Parent, Enclosed is a legal document called an "Affidavit of Direct Payments." This form is used to document child and medical support payments made directly to you by the non-custodial parent (in any form), including payments received in the form of cash or check or from a Military Allotment, Trust Fund or Escrow Account. It should not include any payments made through a county registry or the State Disbursement Unit (SDU). Select the appropriate option on this form to indicate whether or not you have received any support payments directly from the non-custodial parent. If you have received support payments directly from the non-custodial parent, be sure to list the corresponding payment dates and amounts in the spaces provided at the bottom of this form. A Notary Public must notarize this affidavit after witnessing you sign it. Do not sign this form until you are instructed to do so by the Notary Public. This form can be notarized by a Notary Public at your local child support office. Please return the Affidavit of Direct Payments to our office either � � by mail (in the enclosed, postage-paid envelope) or in person. As mentioned above, this form must be completed, signed and notarized before it can be processed. Returning This Form: Please note that this form is needed to process your case. It is very important that you complete this form, have it notarized, and return it to our office, even if no direct payments were received. If no direct payments were received, please select the first check box (indicating you received no direct support payments). If the information requested in this form is not provided, the following may occur: � If you receive TANF, your noncooperation will result in a report to the Health and Human Services Commission (HHSC) to stop cash benefits for you and your family. � � If you receive Medicaid, your noncooperation will stop your Medicaid benefits. Your child(ren) will continue to receive Medicaid. If you do not receive TANF or Medicaid, we may close your case. Reminder: Child and medical support payments are to be made to the State Disbursement Unit at the address below: SDU P.O. Box 659791 San Antonio, TX 78265-9791 If you have any questions concerning this form, please contact our office. November 2014 1A007e American LegalNet, Inc. www.FormsWorkFlow.com � CUSTODIAL PARENT'S AFFIDAVIT OF DIRECT PAYMENTS MC: OAG Case#: Note: This form is used to document child and medical support payments made directly to the custodial parent by the non-custodial parent (in any form), including payments received in the form of cash or check or from a Military Allotment, Trust Fund or Escrow Account. This excludes payments made through a county registry or State Disbursement Unit (SDU). I, __________________________, the custodial parent: � Certify that either: (Please select one of the options below) I have not received any support payments (in any form) directly from ________________________, the noncustodial parent, including payments from a Trust Fund, Escrow Account or Military Allotment, and any payments I received were sent to me from either the county registry or the State Disbursement Unit (SDU) or the list of support payments provided below (including all dates and amounts) is a correct list of payments I received directly from ______________________, the non-custodial parent, and that these payments were not sent to me from either the county registry or the State Disbursement Unit (SDU) authorize and request the Office of the Attorney General of Texas to disclose this document, in its entirety, to ________________________ (the person from whom the below support payments were received) and file it with the court. Date: ______________________ � Custodial Parent's Signature _______________________________ State of Texas County of _______________________________ SUBSCRIBED AND SWORN TO BEFORE ME, the undersigned Notary Public, by ______________________ _______________________, this ______ day of ______________________, 20_____. ___________________________________________ Support Payments Made Directly to the Custodial Parent by the Non-Custodial Parent � � Includes Payments in the form of cash or check or from a Military Allotment, Trust Fund or Escrow Account Excludes Payments made through the County Registry or State Disbursement Unit (SDU) Amount Date Amount Date Amount Date Amount Date Amount Date Cause #: _____________________________________ Total of all direct payments: ________________ Texas Government Code Chapter 559 gives you the right to review and request correction of information on this form. November 2014 American LegalNet, Inc. www.FormsWorkFlow.com 1A007e