NOTARIZED AFFIDAVIT OF DIRECT CHILD SUPPORT PAYMENT Please fill out completely and legibly. Custodial Parent: _____________________________ Non-Custodial Parent: _____________________________ Civil Docket No. _______________ POSSE Case No. _______________ Date: _________________________ I hereby acknowledge that I have received child support directly from the above-named non-custodial parent, in the amount of $_______________, for the month(s) of _______________________, year of ____________. ________________________________ Signature ___________________________________ Mailing Address ___________________________________ C ity, State, Zip ___________________________________ Telephone Number Subscribed and sworn to before me by _____________________________________ this _________ day of ___________________________, 20_____. ___________________________________ Notary Public/Clerk of Court My commission expires: ________________ Return completed, notarized form to: Clerk of District Court th 225 9 Street, Second Floor P.O. Box 1906 Evanston, WY 82931-1906 Phone (307) 783-0430