(1) Person Filing: Street Address: City, State, Zip: Phone Number: Representing Self SUPERIOR COURT OF ARIZONA, COUNTY OF COCONINO Case Number: DO (2) Petitioner: Birthdate: CHILD SUPPORT ORDER A.R.S. 25-503 Respondent: Birthdate: (3) ATLAS Number: THE COURT FINDS THAT: (4) The following parents owe a duty to support the following children: Father: Mother: Child’s Name: Date of Birth: The required financial factors and any discretionary adjustments pursuant to the Arizona Child Support Guidelines are as set forth in the Parent’s Worksheet for Child Support Amount, attached and incorporated by reference. (5) [ ] Mother [ ] Father is obligated to pay support: To: In the amount of: $ (6) (7) (8) (9) Per Month Deviation (only in applicable cases): Application of the Arizona Child Support Guidelines in this case is inappropriate or unjust. The Court has considered the best interests of the child(ren) in determining that a deviation is appropriate. The child support amount before deviation is: $ The child support amount after deviation is: $ The Court finds the guidelines amount is inappropriate or unjust and the deviation is in the children’s best interest because: [] Attached written agreement incorporated. [] Other: Child support arrears exist: In the amount of: For the period of: to: Page 1 of 3 Revised December 2007 $ Arizona Supreme Court American LegalNet, Inc. www.FormsWorkflow.com Interest: In the amount of: For the period of: to: $ A judgment for past care and support should be entered: In the amount of: $ For the period of: to: IT IS ORDERED THAT: (10) [ ] Mother [ ] Father shall pay child support: (11) In the amount of: $ (12) To: First payment is due on the 1st day of: (13) Presumptive termination date: [ ] Mother [ ] Father owes child support arrears: In the amount of: $ For the period of: to: Judgment is ordered in favor of: And against: In the principal amount of: $ [ ] Mother [ ] Father shall pay: $ toward child support arrears until paid in full. OR [ ] Arrears not addressed [ ] Mother [ ] Father owes past care and support: In the amount of: $ For the period of: to: Judgment is ordered in favor of: And against: In the principal amount of: $ [ ] Mother [ ] Father shall pay: $ toward the child past care and support amount until paid in full. OR [ ] Past care and support not addressed. Per Month Per Month Per Month Payment Method: All payments shall be made through the Support Payment Clearinghouse pursuant to an Order of Assignment signed this date. Any time the full amount of support ordered is not withheld, the obligor remains responsible for the full monthly amount ordered. Payments not made directly through the Support Payment Clearinghouse shall be considered gifts unless otherwise ordered by the court or by a written Affidavit of Direct Payments signed by all parties to the case and filed with the Clerk of the Court or the Support Payment Clearinghouse. All payments shall be made payable to and Page 2 of 3 Revised December 2007 Arizona Supreme Court American LegalNet, Inc. www.FormsWorkflow.com mailed directly to: Support Payment Clearinghouse, P.O. Box 52107, Phoenix, AZ 85072-2107. Payments must include the obligor’s name and ATLAS number or Social Security Number. Addresses: Pursuant to A.R.S. § 25-322, the parties shall submit current address information in writing to the Clerk of the Superior Court and the Support Clearinghouse immediately. The obligor shall, within 10 days, submit the names and addresses of employers or other persons or organizations from which he or she is entitled to receive payment. Address Changes: The parties shall submit address changes within 10 days of the change. (14) Travel Related to Parenting Time: The costs of travel related to parenting time over 100 miles one way shall be shared as follows: Mother % Father % Medical, Dental, Vision Care for Minor Children: (15) Mother is responsible for providing [ ] medical [ ] dental [ ] vision care insurance. Father is responsible for providing [ ] medical [ ] dental [ ] vision care insurance. (16) The costs of medical/dental/vision expenses not paid by insurance shall be shared as follows: % Father % Mother 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. Exchange of Financial Information: The parties shall exchange financial information such as copies of tax returns, earnings statements, a Parent’s Worksheet for Child Support Amount, residential addresses and the names and addresses of their employers every 24 months. (17) The court allocates the federal tax exemption(s) for the dependent child(ren) as follows: Parent Entitled to Claim: Me My Spouse Child’s Name Tax Years [] [] [] [] [] [] [] [] [] [] [] [] For years following those listed above while this Child Support Order remains in effect, the parties shall repeat the pattern above of claiming deductions for each child. Each year, the obligor may claim these exemptions only of the obligor has paid all child support and arrears ordered for the year by December 31 of that year. IMPORTANT INFORMATION: If this is a modification of child support, all other prior orders of this Court not modified remain in full force and effect. Date: Page 3 of 3 Revised December 2007 Judicial Officer: Arizona Supreme Court American LegalNet, Inc. www.FormsWorkflow.com