Fillable IN THE CIRCUIT COURT, OF THE FOURTH JUDICIAL (Clay County Florida Clerk of Court and Comptroller)

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IN THE CIRCUIT COURT, OF THE FOURTH JUDICIAL (Clay County Florida Clerk of Court and Comptroller)

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IN THE CIRCUIT COURT, OF THE FOURTH
JUDICIAL CIRCUIT, IN AND FOR CLAY
COUNTY, FLORIDA.
PAYEE CASE NO.:
VS. DIVISION:
PAYOR
Date of Birth:
Driver’s License #:
REQUEST TO SUSPEND DRIVER’S LICENSE AND
MOTOR VEHICLE REGISTRATION
I, hereby request the Central Governmental Depository
to initiate driver’s license suspension action against the above named Payor in accordance with the provisions of F.S. 61.13016
and 322.058.
To the best of my knowledge, the Payor’s current address is:
DATED this day of , 20 .
Payee’s Signature
Payee’s Address:
City/State/Zip
CC: New Address: Yes No
____________________________________ appeared before me and acknowledged that he/she signed the foregoing this
_________________ day of __________________________, 20______.
________________________________________Notary Public,
State of Florida or Deputy Clerk
Seal
R Check one only:
Personally known
Produced identification
Type of identification produced__________________________________________
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IN THE CIRCUIT COURT, OF THE FOURTH JUDICIAL (Clay County Florida Clerk of Court and Comptroller)

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Completed 30 July 2021

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