251 Superior Court of Arizona in Maricopa County Page 1 of 3 DRMSS11f - 010119 ALL RIGHTS RESERVED SSM Person Filing: (A) Address (if not protected): City, State, Zip Code: Telephone: Email Address: ATLAS Number: Representing Self, without a Lawyer or Attorney for Petitioner OR Respondent SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY (B) Case Number: (C) Name of Petitioner/Party A (in original case) PETITION TO MODIFY (change) CHILD SUPPORT (B) Name of Respondent/Party B, (in original case) IMPORTANT NOTICE TO PARTY NOT REQUESTING THE MODIFICATION (CHANGE). Your support order may be modified (changed) if you do not request a hearing. 1. Party A or Party B asks this court to modify the Arizona child support order: The Order was issued on: (Month/Day/Year) The Order was issued by: (Name of Court) Located in this County: If the Order was not issued by the Superior Court of Arizona in this county , the case has already been transferred to this county and has a Maricopa County case number. 2. Under the current child support order: Party A is responsible for providing medical dental vision care insurance Party B is responsible for providing medical dental vision care insurance Neither party was ordered to provide medical dental vision care insurance American LegalNet, Inc. www.FormsWorkFlow.com Case No. 251 Superior Court of Arizona in Maricopa County Page 2 of 3 DRMSS11f - 010119 ALL RIGHTS RESERVED 3. The child support order currently in effect requires Party A or Party B to make payments of (b) $ per , payable on the day of the month. 4. Attached is a Child Support Worksheet. According to the worksheet calculations, the child support amount should be $ per month. 5. The following calculations show that the new amount varies from the current amount of court-ordered child support by 15% or more. (a) divided by (b) = (c) % a = the difference between the amount currently ordered and the amount requested; b = the amount currently ordered; and, c = the percentage change 6. Is the Department of Economic Security or the Division of Child Support Enforcement (DES or DCSE) providing services to at least one of the parties? Yes No Unknown (If YES, see instructions regarding notice to the State in the packet.) 7. Other court-ordered payments included in the current Order of Assignment dated / / Spousal Maintenance: $ per Payments on Arrears: $ per Other: $ per RELIEF REQUESTED (WHAT I WANT THIS COURT TO DO): A. I request that child support be ordered in the amount of $ per month to be paid by Party A or Party B, and that relief requested in the Child Support Worksheet be ordered. B. Regarding insurance for minor children, order that: Party A is responsible for providing medical dental vision care insurance. Party B is responsible for providing medical dental vision care insurance. The costs of medical/dental/vision care expenses not paid by insurance shall be shared as follows: Party A % Party B %. Request for payment or reimbursement must be provided to the obligated parent(s) within 180 days after the services occurred. The obligated parent must pay or make payment arrangements within 45 days after receipt of the request. C. If this matter goes to hearing, I further request that costs and fees incurred in bringing this action be ordered to be paid by the opposing party. American LegalNet, Inc. www.FormsWorkFlow.com Case No. 251 Superior Court of Arizona in Maricopa County Page 3 of 3 DRMSS11f - 010119 ALL RIGHTS RESERVED UNDER OATH OR BY AFFIRMATION I swear or affirm under penalty of perjury that the contents of this document are true and correct to the best of my knowledge and belief. Date Signature STATE OF COUNTY OF Subscribed and sworn to or affirmed before me this: by (date) . (notary seal) Deputy Clerk or Notary Public NOTICE TO PARTIES If you do not agree with the modification/change in child support, you have twenty (20) days to ask for a hearing. If service of process is made outside the State of Arizona, the parent receiving service has 30 days in which to ask for a hearing. Upon proof of service and if no hearing is requested within the time allowed, the court will review the request and enter an appropriate order modifying the support award. If an error is noted, the amount awarded may be different from the amount requested , but the modification will not be greater than the amount requested. In the event the court has serious concerns regarding the accuracy of the information, or if a substantial mathematical error is found, the court may set the matter for hearing. The co urt will set a hearing if requested by either party within the time allowed. No order will be modified without a hearing if a hearing is requested. The forms necessary to request a hearing (below) may be downloaded for free from the Law Library Resource C enter webpage or purchased at any LLRC location. Request for Hearing Child Support Worksheet American LegalNet, Inc. www.FormsWorkFlow.com