IN THE CIRCUIT COURT OF THE TENTH JUDICIAL CIRCUIT

IN AND FOR POLK COUNTY, FLORIDA

___________________________________,

Payee, CASE NO._____________

vs. DRD NO.______________

___________________________________,

Payor.

STATE OF FLORIDA

COUNTY OF POLK

Before the undersigned authority personally appeared ________________________, who, having been duly sworn, deposes and says:

1. Name of Payor: ________________________________

________________________________

________________________________

Phone:______________________ Social Security #:__________________________

Date of Birth:________________

Employer:_________________________________________

Other source of income:_____________________________

Attorney for Payor:_________________________________

2. Name of Payee: ________________________________

________________________________

________________________________

Phone:______________________ Social Security #:__________________________

Date of Birth:________________

Employer:_________________________________________

Other source of income:_____________________________

Attorney for Payee:_________________________________

3. The following named children currently reside with me:

__________________________ born _________________________

__________________________ born _________________________

4. The Order of this Court dated ________________________, required payor to pay to the payee child support or alimony, the sum of $_________ each _____________, with the first such payment due on _________________________.

5. Payor is presently in default in these payments and is in arrears in the amount of

$__________ as of the payment due __________________________.

6. Under Section 61.13, Florida Statues, affiant now requests participation in the

Central Governmental Depository, and requests the payor be notified immediately

to make all future payments required by the above-cited Order to the Central

Governmental Depository.

DATE:___________________________ __________________________________

Affiant

The foregoing instrument was acknowledged before me this _____ day of ___________________, 1997, by _______________________, who is personally known to me or who has produced ______________________________ as identification and who did (did not) take an oath.

Richard M. Weiss

Clerk of Courts

By:______________________________

Deputy Clerk