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) Case Number Petitioner (4) PETITION TO ENFORCE (2) Respondent (5) Child Support Child Support Arrears Spousal Maintenance (alimony) Spousal Maintenance Arrears Medical Insurance Coverage Medical Expense Reimbursement ATLAS No. (3) SECTION A: Complete this section ONLY if you marked boxes above to enforce Child Support and/or Child Support Arrears. On this date (1) , the Honorable (2) , a Judicial to pay child Officer of the Superior Court of Arizona, ordered (3) support as follows: (4) The total amount of child support past due beginning from the first court order to present is (5) $ , for the time period beginning (6) , through . Child support payments made directly to me since the first court order are (7) __________________. (If the amount is more than zero, please complete an Affidavit of Direct Payment and file it with this Petition) � Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED ESE DRESE11f - 081216 Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case No. SECTION B: Complete this section ONLY if you marked boxes above to enforce Spousal Maintenance (alimony) and/or Spousal Maintenance Arrears. On this date (1) , the Honorable (2) , a Judicial to pay Officer of the Superior Court of Arizona, ordered (3) spousal maintenance as follows: (4) The total amount of spousal maintenance past due and owed since the first court order is (5) $ for the time period beginning (6) , through . , Spousal maintenance payments made directly to me since the first court order are (7) __________________. (If the amount is more than zero, please complete an Affidavit of Direct Payment and file it with this Petition.) SECTION C: Complete this section ONLY if you marked any of the boxes to enforce: Medical Insurance Coverage or Reimbursement of Medical / Dental / Vision Care Expenses. On this date (1) , the Honorable (2) , a Judicial to Officer of the Superior Court of Arizona, ordered (3) obtain medical insurance coverage and/or to pay the following percent of uninsured medical, dental or vision expenses as follows: (4) The time period for which medical insurance coverage was not provided is from (5) ____________ to ______________________. I have completed and attached "Attachment A", the "Unreimbursed Medical Expense Worksheet", a chronological (earliest to most recent) summary of all bills claimed, insurance payments, personal payments, and the remaining unpaid balance on each bill. The Worksheet shows the total amount of medical, dental or vision care expense reimbursement that is past due is (6) . Documentation of these expenses has been presented to the other party and reimbursement is more than 30 days past due. � Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED ESE DRESE11f - 081216 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case No. REQUESTS TO THE COURT I request that the Court consider any or all of the following action(s): � � � � � � � � Order the other person to bring to the conference those items set forth in the Order to Appear. Enter judgment for past-due support, un-reimbursed uninsured medical/dental/vision care expenses, clerk's fees, service costs, and other court costs against the other party. Enter an Income Withholding Order to require the other person's employer to take money for the following from the other person's paycheck: current child support, child support arrears, current spousal maintenance, and/or spousal maintenance arrears. Order the other person to pay support through the Support Payment Clearinghouse. Find the other party in civil contempt of court and order sanctions including but not limited to, incarceration and the posting of a surety bond. Issue a civil or child support arrest warrant if the other party fails to appear, and/or enter a default judgment. Order the other party to provide evidence of medical insurance coverage within a fixed period of time. Order other relief as deemed just and proper by the court. OATH OR AFFIRMATION for PETITION TO ENFORCE SUPPORT ORDER I state to the Court under penalty of perjury that the contents of this document are true and correct to the best of my knowledge and belief. Date STATE OF Signature COUNTY OF Subscribed and sworn to or affirmed before me this: (date) . by (notary seal) Deputy Clerk or Notary Public � Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED ESE DRESE11f - 081216 Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case No. IMPORTANT INFORMATION After this petition is filed with the Clerk of the Court you must get an Order to Appear from the Family Court Conference Center. The Order to Appear will tell you what information you need to bring to court and the date and time of your conference and hearing. The person who filed the petition must arrange delivery of the petition and the Order to Appear to the other person. Delivery may be by licensed process server, law enforcement officer, or by return receipt mail or commercial delivery service (such as FedEx, DHL, or UPS) where you can obtain a copy of the other party's signature of receipt to file with the Court. You may only hand-deliver or otherwise send without proof of delivery if the other person will sign an Acceptance of Service, in front of a Notary Public or a Clerk of the Superior Court, and will return that form for you to file with the Court. The conference and hearing may last two hours and additional conferences or hearings may be scheduled if needed. Conferences are for the Petitioner and the Respondent. Attorneys are invited to attend and participate in the conference. Spouses, children, family members, significant others, and friends will not be allowed in the conference. DO NOT BRING CHILDREN. They will not be allowed in the conference or hearing and may NOT be left unattended. � Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED ESE DRESE11f - 081216 Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com