Account #: Date Opened: Clerk's Initials:

INTERNAL USE ONLY

*** PLEASE TYPE OR PRINT CLEARLY ***

PINELLAS COUNTY CLERK OF THE CIRCUIT COURT APPLICATION FOR DEPOSIT ACCOUNT

Account Name: Address:

City: State: Zip:

Telephone #: ( ) Fax #: ( ) E-Mail Address:

Contact Person: Signature:

I give the Clerk's Office permission to charge my Deposit Account for

( Initial ) amounts greater than ten dollars ($10.00) whenever money sent to cover fees for a transaction is not sufficient. I also give permission to have overpayments of ten dollars ($10.00) or less automatically deposited into my Deposit Account.

*** Please mail completed application and check to *** Clerk of the Circuit Court

Accounting Dept. 4th Floor

315 Court Street Rm 449

Clearwater, Fl 33756

Attn: Deposit Accounts

If you have any questions, please contact Angela Moore at (727) 453-7663 amoore@pinellascounty.org or Demetrius Middleton at (727) 453-7656 dmiddleton@pinellascounty.org