Child Support Application for Income Withholding

IN THE CIRCUIT COURT OF JACKSON COUNTY, MISSOURI ______________________________ Petitioner, and ______________________________ Respondent. Case No. ________________________ AFFIDAVIT OF CREDIT BY CUSTODIAN PARENT Custodian Parent: Non-Custodial Parent __________________________ __________________________ Direct Payment: I have received a direct payment for child support/maintenance in the amount of $__________ from the non-custodial parent. Note: Credit may only be given for past-due support debt. NOTE: Credit may not be given for a payment not yet due. Credit for direct payment on all open IVD cases must be reported directly to the appropriate case worker. Explanation of Credit: _______________________________________________________________ Payment Forgiven: I hereby forgive the non-custodial parent’s child support/maintenance past-due support debt in the amount of $___________. NOTE: Credit may not be given for a payment not yet due. Credit for a direct payment on all open IVD cases must be reported directly to the appropriate case worker. The facts in this Affidavit are true to my best knowledge and belief and are made under penalty of perjury. ___________________________ (Date) ________________________________________________ Custodial Parent’s Signature This affidavit must be completed and signature witnessed by a court clerk or notary before filing with the court. In witness thereof: ____________________________ Date _______________________________________________ Court Clerk Witnessing Signature Subscribed and sworn to before me on _______________________________________________________ My commission expires:___________ Date Send all completed forms to: Department of Civil Records Child Support Section 415 E. 12th Street - Room 305 Kansas City, Missouri 64106-2706 CIRCT 1426A – 03-08 _______________________________________________ Notary Public