Memorandum To Clerk Form - Florida

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IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT, IN
AND FOR _____________COUNTY, FLORIDA
REF:_____________________________
UCN:_____________________________
Division:__________________________
__________________________________ ,
Petitioner,
and
___________________________________ ,
Respondent.
DATE:________________________, ______
MEMORANDUM TO CLERK
The Court has this date ordered the payment of the herein specified money in the amounts and at the times
indicated below.
OBLIGOR: PERSON WHO PAYS SUPPORT
1.
NAME ______________________________________________________ DOB:______________
SOCIAL SECURITY # __________________________________________ PHONE:___________
ADDRESS:____________________________________________________ ZIP CODE:_________
2.
PLACE OF EMPLOYMENT:_________________________________________________________
ADDRESS:________________________________________________________________________
________________________________ZIP CODE: ___________PHONE:____________
3.
OTHER SOURCES OF INCOME:______________________________________________________
4.
ATTORNEY FOR OBLIGOR:_________________________________________________________
______________________________________________________________PHONE:____________
PAYMENT FOR: child support/alimony PAYMENT AMOUNT:________ PLUS________toward
retroactive support/support arrears of (amount)_____________as of (date)_____________________
WEEKLY/SEMI-MONTHLY/MONTHLY
FIRST PAYMENT DUE:______________________
PLUS APPLICABLE CLERK’S FEES.
OBLIGEE: PERSON WHO RECEIVES SUPPORT
1.
NAME _______________________________________________________DOB:_______________
SOCIAL SECURITY # __________________________________________PHONE:____________
ADDRESS: ____________________________________________________ZIP CODE:__________
2.
ATTORNEY FOR OBLIGEE:_________________________________________________________
______________________________________________________________PHONE:____________
REMARKS OR INSTRUCTIONS:_____________________________________________________
________________________________________________________Prepared By________________
CHILDREN
Full Name:_________________________Social Security No.__________________ D.O.B:____________
Full Name:_________________________Social Security No.__________________ D.O.B:____________
Full Name:_________________________Social Security No.__________________ D.O.B:____________
SEND PAYMENTS TO:
_____SDU, P.O. Box 8500, Tallahassee, Florida 32314-8500
_____Central Governmental Depository, Pinellas County Clerk of the Circuit Court, 315 Court Street, Clearwater, FL 33756
_____Central Governmental Depository, Pasco County Clerk of the Circuit Court, P.O Drawer 338, New Port Richey, FL 34656
_____Central Governmental Depository, Pasco County Clerk of the Circuit Court, 38053 Live Oak Avenue,
Dade City, FL 33523-3894
_____Payable directly to the Obligee
Sixth Judicial Circuit Local form, Memorandum to Clerk-Pinellas/Pasco 1-2003

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