(1) Person Filing: Mailing Address: City, State, Zip: Phone Number: Representing Self SUPERIOR COURT OF ARIZONA, COUNTY OF COCONINO (2) Petitioner: DOB: (4) Case Number: DO REQUEST TO MODIFY CHILD SUPPORT SIMPLIFIED PROCEDURE (3) Respondent: DOB: (5) ATLAS Number: IMPORTANT NOTICE TO THE PARTY NOT REQUESTING THE MODIFICATION (CHANGE): Your support order may be changed if you do not request a hearing. I STATE THE FOLLOWING UNDER OATH: (6) I am [ ] the obligor or [ ] the obligee. My Name: (7) The current Child Support Order is dated: Signed by: The current monthly child support amount is: $ Obligor’s Name: . (8) According to the attached Parent’s Worksheet for Child Support Amount, the monthly child support amount should be changed to $ . The requested amount varies from the current amount by at least 15%: (9) (a) ÷ (b) = (c) a = the difference between the amount currently ordered and the amount requested b = the amount currently ordered, c = the percentage change (10) [ ] Yes [ ] No [ ] Unknown: The Department of Economic Security provides child support enforcement services to at least one of the parties. Page 1 of 3 Revised April 2009 Coconino County Law Library and Self-Help Center Forms American LegalNet, Inc. www.FormsWorkFlow.com (11) Other court-ordered payments in the current Order of Assignment dated: Spousal Maintenance: $ per Payments on Arrears: Child Support: $ per Spousal Maintenance: $ per Other: $ per I ASK THE COURT TO ORDER THE FOLLOWING: (12) Order child support in the monthly amount of $ Parent’s Worksheet. , and order the relief requested in the (13) Divide our income tax dependency exemptions as follows: Parent Entitled to Claim Petitioner Respondent Child’s name [] [] [] [] [] [] [] [] [] [] [] [] Tax years If this matter goes to hearing, order that the other party pay the costs and fees incurred in bringing this action. Copy to Judge: I will mail or hand-deliver a copy of this Request to the judge. (14) OATH AND VERIFICATION: I have read this document, and it is true and complete to the best of my knowledge. My Signature: State of Arizona ) ) ) County of Subscribed and sworn before me this date: Seal: by: Notary Public: Notary Expiration Date: NOTICE TO PARTIES If you do not agree with the change in child support, you have 20 days, including weekends and holidays, beginning the day after you were served, to file a request for a hearing. If service of process is made outside Page 2 of 3 Revised April 2009 Coconino County Law Library and Self-Help Center Forms American LegalNet, Inc. www.FormsWorkFlow.com Arizona, you have 30 days, including weekends and holidays, beginning the day after you were served, to file a request 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 support. If an error is noted, the amount awarded may be different from the amount requested, but the change will not be more than the amount requested. If 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. If either party requests a hearing within the time allowed, the court will set a hearing. No order will be modified without a hearing if a hearing is requested. If you wish to request a hearing, see the Self-Help Center packet, Changing Child Support: Response. An arrearage calculation may be completed on your case. If it is determined that there is an overpayment or an arrearage owing, the monthly obligation could be adjusted to bring your case current. Page 3 of 3 Revised April 2009 Coconino County Law Library and Self-Help Center Forms American LegalNet, Inc. www.FormsWorkFlow.com