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 FOR CLERK'S USE ONLY Respondent SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY (2) Name of Petitioner (in original case) (3) CASE NO: PETITION FOR EX PARTE INCOME WITHHOLDING ORDER A.R.S. §25-504 Name of Respondent (in original case) On (4) (date),(5) (name , the person ordered to of court, example: pay support, was ordered in (6) "Superior Court") state) to pay: (8) $ $ $ $ monthly child support payment monthly spousal maintenance payment monthly child support arrearage payment monthly spousal maintenance arrearage payment in (7) (location of court: county and (9) I request that an Ex Parte Income Withholding Order be issued because: (check all that apply) I am the person entitled to the support or I represent the agency entitled to collect the support, and there is no existing Income Withholding Order © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED WAH DRWA11f - 050115 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case No. _______________________ A past due obligation exists for child support, spousal support, spousal support arrears or interest and I request payment on past due support in the amount of $ per month I am the person required to pay the support and there is no existing Income Withholding Order, and I hereby voluntarily request an Income Withholding Order be issued for payment of my obligation. STATE OF COUNTY OF Subscribed and sworn to or affirmed before me this: (date) . by (notary seal) Deputy Clerk or Notary Public Signature of person requesting Assignment Name of Agency if Applicable © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED WAH DRWA11f - 050115 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com