Memorandum To The Clerk Form - Circuit Court For The Twelfth Judicial Circuit In And For Manatee County Page 2
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1
2PAYEE INFORMATION:
1.
Name: __________________________________ Home Telephone: ___________________
Address:
__________________________________________________________________________
__________________________________________________________________________
Social Security Number: _____________________ Work Phone: ______________________
Date of Birth: ___________________________________
2.
Attorney for
Payee:_________________________________________________________________
4.
Children:
Name
Date of Birth
Social Security Number
_____________________________
_________________
_______________________
_____________________________
_________________
_______________________
_____________________________
_________________
_______________________
_____________________________
_________________
_______________________
_____________________________
_________________
_______________________
_____________________________
_________________
_______________________
PAYMENT INFORMATION:
1.
Alimony Payable
$____________________ per _______________________
Current Child Support
$____________________ per _______________________
Arrears Total
$____________________ as of ______________________
Payable
$____________________ per _______________________
Medical Total
$____________________ as of ______________________
Payable
$____________________ per _______________________
Medical Insurance Payable
$____________________ per _______________________
Attorney Fees/Costs
$____________________ within _________________ days
HLA Fees
$____________________ within _________________ days
Clerk’s Fee
$___________________
2.
TOTAL $_________________________
FIRST PAYMENT DUE ON:___________________________________
3.
Other:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
DATED ON THIS ___________ DAY OF _____________________, 19____.
__________________________________
Signature
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