Name: Mailing Address: Daytime Telephone: ATLAS # For Office Use Only : [ ] IV-D (If Child Support or Medical) [ ] NON IV-D For Clerk's Use Only IN THE SUPERIOR COURT OF ARIZONA, YAVAPAI COUNTY 1300DO Petitioner PETITION TO ENFORCE SUPPORT vs. [ [ [ [ [ [ ] ] ] ] ] ] Child Support Child Support Arrearages only Medical Insurance Coverage Spousal Support Medical, Dental or Vision Costs Other sums owed pursuant to child support order [] Expedited Respondent STATEMENTS TO THE COURT UNDER OATH: 1. Petitioner's Name: Address: Respondent's Name: Address: CURRENT ORDER. [] I have a current support order by the Superior Court in Yavapai County. Date of order [] I have a current support order from the Superior Court in Arizona but not from Yavapai County and I am filing or have already filed a certified copy with this Court. Name of county Date of Order [] I have a current support order from another state and I am filing or have already filed a certified copy with this Court. Name of county Date of Order [] The current order requires the [ ] Petitioner [ ] Respondent to pay the [ ] Petitioner [ ] Respondent the following: [ ] child support; Date of Birth 2. Date of Birth 3. Superior Court of Arizona in Yavapai County July 2013 Page 1 of 3 CSEnforcePetition Use only most current version American LegalNet, Inc. www.FormsWorkFlow.com [ ] spousal support; [ ] medical insurance coverage; [ ] medical, dental or vision costs; [ ] Pay other: What the Order says: 4. [] Current enforcement or modification cases: No other cases are pending in any court for enforcement or modification of this court order for support. (YOU MUST CHECK HERE, AND THIS MUST BE TRUE) 5. ANY OTHER COURT CASES THAT INVOLVE THESE PARTIES: Describe any other court cases that involve these same parties, whether still pending or not, and complete all the information for each court order (use extra paper if necessary; if no such cases, write "none") Names of Parties: Explain Type of Case: Court Case No.: Date of order, judgment, dismissal, etc.: Explain what order or judgment said, or basis for dismissal: Location of court (city and county): Status of Case Now [ ] Final Order Entered; Case is over [ ] Hearing Date Set: on (date) Court location/address: [ ] Other (explain in detail): at (time) 6. SUPPORT AMOUNT DUE. The total amount of support past due is $ for the time period to with a portion of this due during the past year. The other party is more than 30 late in his/her payments (this must be true). [ ] A calculation of arrears from the Department of Child Support Services is attached. [ ] I am providing a statement of the arrears owed showing how I determined the amount. [] I am requesting reimbursement of medical, dental, or vision costs and have completed the Health Care Worksheet below. Documentation of these expenses has been given to the other party and reimbursement is more than 30 days past due. Type of bill: Total amount of bill: Amt. paid by third party: Amt. paid by Petitioner: Amount paid by Respondent: Unpaid balance: Amt. owed by Petitioner: Amt. owed by Respondent: Type of bill: Total amount of bill: Amt. paid by third party: Amt. paid by Petitioner: Amt. paid by Respondent: Unpaid balance: Amt. owed by Petitioner: Amt. owed by Respondent: 7. Type of bill: Total amount of bill: Amt. paid by third party: Amt. paid by Petitioner: Amt. paid by Respondent: Unpaid balance: Amt. owed by Petitioner: Amt. owed by Respondent: 8. [] EXPEDITED PROCESS. I am requesting an expedited process because Superior Court of Arizona in Yavapai County July 2013 Page 2 of 3 CSEnforcePetition Use only most current version American LegalNet, Inc. www.FormsWorkFlow.com 9. I estimate the length of time necessary for the hearing to be [ ] hours. Other: [ ] minutes OR 10. REQUESTS TO THE COURT A. B. C. D. E. F. G. H. I. J. Order the other party to bring to court at the time of the scheduled conference/hearing all those items set forth in the Order to Appear. Enter judgment for past-due support, unreimbursed medical, dental or visions costs, filing/service/other court costs and attorney fees against the other party. Enter an Order of Assignment for payments on current support, past-due support and clerk's fees against the other party. Order the other party to pay support through the Clearinghouse. Find the other party in contempt of court and order sanctions that may include, but are not limited to, incarceration and the posting of a surety bond. Issue a civil arrest warrant if the other party fails to appear and/or enter a default judgment. Order referral to a professional licensing board/agency to determine the possible suspension of the other party's professional license or certificate. Order the other party to provide evidence of medical insurance coverage within a fixed period of time. Such other relief as deemed just and proper by the Court. Other: OATH AND VERIFICATION State of Arizona County of Yavapai ) ) I , being duly sworn and under oath, state that I have read this Petition and the contents are true and correct to the best of my knowledge, information and belief. I understand that if the judicial officer finds that I did file this for an improper purpose, contempt or other sanctions may be ordered against me, including assessing me for any and all reasonable costs, attorney fees, or other expenses associated with the improper filing. SIGNED SUSCRIBED AND SWORN to before me this day of . , 20 , by My commission expires: Notary Public Superior Court of Arizona in Yavapai County July 2013 Page 3 of 3 CSEnforcePetition Use only most current version American LegalNet, Inc. www.FormsWorkFlow.com