Memorandum To Clerk Form

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IN THE CIRCUIT COURT IN AND FOR ESCAMBIA COUNTY, FLORIDA
MEMORANDUM TO CLERK
To:
Clerk, Circuit Court, Domestic Relations Division
Subject:
Payment and Disbursement of Child Support or Alimony; State Case Registry Information
Style of Case: _________________________________________________________________________
Case Number:____________________________ Date of Order: ________________________________
************************************************************************************
PAYMENT INFORMATION
Amount for: Child Support $___________ Alimony $_____________
Arrearage $_____________
Payable:
_______ Weekly ______ Bi-Weekly _______ Semi-monthly _____Monthly _____ Yearly
First Payment Due: ______________________ Clerk=s fee payed by: _____Obligor _____ Obligee
Arrearage:
$______________ as of ____________________ for _____ Child Support _____ Alimony
************************************************************************************
OBLIGOR
Name: ______________________________________________________________________________
Mailing Address: __________________________________________________ Zip Code___________
Date of Birth: _________________________________ SSN: _________________________________
************************************************************************************
OBLIGEE
Name: ______________________________________________________________________________
Mailing Address: __________________________________________________ Zip Code___________
Date of Birth: _________________________________ SSN: _________________________________
************************************************************************************
CHILDREN
1. _____________________________________ DOB: _________________ SSN:__________________
2. _____________________________________ DOB: _________________ SSN:__________________
3. _____________________________________ DOB: _________________ SSN:__________________
4. _____________________________________ DOB: _________________ SSN:__________________
************************************************************************************
Family Violence Indicator present?
________ Yes ________ No
Court Order entered against Obligor in a domestic violence or protective action: _____ Yes _____ No
Court Order entered against Obligee in a domestic violence or protective action: _____ Yes _____ No
************************************************************************************
Remarks: ____________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
I certify that the information in this Memorandum is correct and complete to the best of my knowledge.
Signature: __________________________________________
Print Name: ________________________________________
Signer is: ____Attorney for Obligor ____ Attorney for Obligee ____Obligor (pro se) ____Obligee (pro se)

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