Person Filing: Address (if not protected): City, State, Zip Code: Telephone: Email Address: ATLAS Number: Lawyer's Bar Number: Representing Self, without a Lawyer or Attorney for Petitioner OR Respondent FOR CLERK'S USE ONLY SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY (2) Petitioner (in original case) (3) Case No. (4) ATLAS No. (2) Respondent (in original case) AGREEMENT TO MODIFY INCOME WITHHOLDING ORDER A.R.S. § 25-504 An Income Withholding Order is a court order that requires an employer or other payor to withhold money from the funds of a person ordered to pay child support and/or spousal maintenance (alimony). THIS FORM WILL NOT AFFECT THE AMOUNT OF SUPPORT ORDERED PAID; IT ONLY AFFECTS THE AMOUNT OF SUPPORT DEDUCTED FROM PAY. I, (5a) , the person ordered to make payments, and I, (5b) modify the Income Withholding Order: , the person receiving payments, ask the Court to © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED SSO DRMWA11f - 090115 Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case No. __________________ Issued this date: (6) Issued by this Court: Located in this County: Located in this State: because: (Check the appropriate box(s)) (7) The amount shown on the Income Withholding Order is wrong because: (7a) The amount was changed by Court Order issued on this date: (Month/Day/Year) in this county: , OR (Month/Day/Year) (Name of Court) (Name of County) (Name of State) (7b) The person making payments no longer owes (Check all that apply) Current Child Support. Child Support arrearages (back child support) and interest Current Spousal Support Spousal Support arrearages (back alimony) and interest Reason(s) why money is no longer owed for any items checked in item (7b): (List and attach any supporting documents.) (8) For the reasons listed in above, the amount ordered assigned should be changed from the current Amount of (8a) $ to the new amount of (8b) $ (9) The current Income Withholding Order should be modified because the presumptive termination date (the day the order will end) is wrong. The termination date should be changed from the date listed on the current Income Withholding Order: (9a) __________________ (Month/Day/Year) To the new date of : (9b) (Month/Day/Year) Explain why the presumptive termination date is wrong (list and attach any supporting documents) © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED SSO DRMWA11f - 090115 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case No. __________________ Do not write or sign below this line until you are instructed to do so by Court Clerk or Notary. 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. Petitioner's Signature Respondent's Signature STATE OF STATE OF COUNTY OF COUNTY OF Subscribed and sworn to or affirmed before me this: (date) Subscribed and sworn to or affirmed before me this: (date) By . By . Deputy Clerk or Notary Public (notary seal) Deputy Clerk or Notary Public (notary seal) If the State of Arizona is a party to your case, a representative of the Attorney General's Division of Child Support Enforcement (DCSE) must also sign this form before you file. (See Instructions) Signature of DCSE representative Date Date © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED SSO Judge of the Superior Court DRMWA11f - 090115 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com