Fillable CENTRAL GOVERNMENTAL DEPOSITORY P.O. BOX 698, GREEN COVE (Clay County Florida Clerk of Court and Comptroller)

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CENTRAL GOVERNMENTAL DEPOSITORY P.O. BOX 698, GREEN COVE (Clay County Florida Clerk of Court and Comptroller)

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PLEASE RETURN THIS FORM TO:
CENTRAL GOVERNMENTAL DEPOSITORY
P.O. BOX 698, GREEN COVE SPRINGS, FL 32043-0698
OR FAX (904) 278-3610
Date: Case No.:
DATES OF BIRTH AND SOCIAL SECURITY NUMBERS ARE REQUIRED PER FLORIDA STATUTE § 61.052(7)(8)
Petitioner Information (person receiving payment): Respondent Information (person making payment):
Name Name
Social Security Number Date of Birth Social Security Number Date of Birth
Mailing Address Mailing Address
City State Zip Code City State Zip Code
Home Telephone Work Telephone Home Telephone Work Telephone
Driver’s License Number Driver’s License Number
Email Address Email Address
Children Information:
Name Social Security Number Date of Birth
Name Social Security Number Date of Birth
Name Social Security Number Date of Birth
Name Social Security Number Date of Birth
Name Social Security Number Date of Birth
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CENTRAL GOVERNMENTAL DEPOSITORY P.O. BOX 698, GREEN COVE (Clay County Florida Clerk of Court and Comptroller)

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Completed 30 July 2021

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