FOR CLERK’S USE ONLY SUPERIOR COURT OF ARIZONA MOHAVE COUNTY Case Number:_________________________ (Name of Petitioner) ATLAS Number: _______________________ CHILD SUPPORT ORDER A.R.S. §25-503 AND _____________________________________ (Name of Respondent) THE COURT FINDS THAT: 1. Mother’s Name: ___________________________________ Date of Birth: ____________________ Social Security # _____________________________(*Can be omitted if using the Confidential Sensitive Data Form) Father’s Name: __________________________________ Date of Birth: ____________________ Social Security # _____________________________(*Can be omitted if using the Confidential Sensitive Data Form) Owe a duty to support the following children: (*Social Security # can be omitted if using the Confidential Sensitive Data Form) Child(ren)’s Names(s) Date of Birth Social Security # ______________________________________ _______________________ _________________________ ______________________________________ _______________________ _________________________ ______________________________________ _______________________ _________________________ ______________________________________ _______________________ _________________________ ______________________________________ _______________________ _________________________ DO NOT WRITE BELOW THIS LINE. COURT PERSONNEL WILL COMPLETE THE FORM 2. 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. Mother 3. Father is obligated to pay support to:____________________________________ In the amount of: $ ___________________________ per month. 4. 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. 6/26/09 Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case No.____________________________ The child support amount before deviation is: $ _____________________________ The child support amount after deviation is: $ _____________________________ The Court finds the guidelines amount is inappropriate or unjust because: __________________________________________________________________________________ __________________________________________________________________________________ The attached written agreement is made part of this order by reference Other Reasons for Deviation from Guideline Amount: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Arrears Child support arrears exist in the amount of: $ ____________________________ For the period of: __________________________________ to __________________________________ Interest Interest in the amount of: $ ___________________________ For the period of: __________________________________ to __________________________________ Past Care and Support A judgment for past care and support should be entered in the amount of: $______________________ IT IS ORDERED THAT: 1. Mother per month, to: Father shall pay child support in the amount of: $ _____________________ _______________________________________ First payment is due on the 1st day of: _____________________ Mother 2. 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 $ _____________________________ per month toward child support arrears until paid in full, OR Arrears not addressed. 3. Mother Father owes past care and support in the amount of: For the period of: ________________________________ to ________________________________ Judgment is ordered in favor of: And against: 6/26/09 $ _____________________ ______________________________________ ______________________________________ Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case No.____________________________ In the principal amount of: $ _____________________________ Mother Father shall pay $ _____________________________ per month toward the past care and support amount until paid in full, OR Past care and support not addressed. 4. 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 person obligated to pay (the obligor) remains responsible for the full monthly amount ordered. Payments not made directly through the Support Payment Clearinghouse may be considered a gift unless you have a notarized affidavit signed by the other party agreeing that he or she received the payment and that it was for child support. All payments not made by Order of Assignment shall be made payable to and mailed directly to: Support Payment Clearinghouse P.O. Box 52107 Phoenix, AZ 85072-2107 Payments must include the payor’s name, ATLAS number or Social Security Number. 5. 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 payor 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. 6. The parties shall submit address changes within 10 days of the change. 7. MEDICAL, DENTAL, VISION CARE INSURANCE FOR MINOR CHILDREN Mother is responsible for providing medical dental vision care insurance. Father is responsible for providing medical dental vision care insurance. 8. The costs of medical/dental/vision care expenses not paid by insurance shall be shared as follows: Mother _______________% Father _______________% 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. 9. The costs of travel related to parenting time over 100 miles one way shall be shared as follows: Mother _______________% Father _______________% 10. 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. 11. The Court allocates the federal tax exemption(s) for the dependent child(ren) as follows: Date of Birth Child’s Name Parent Entitled to Deduction (Month, Day, Year) Mother Father Mother Father Mother Father Mother 6/26/09 Father Mother For Calendar Year Father Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case No. ____________________________ 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. 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. Pursuant to Arizona Revised Statutes §25-503(l), the right to get a judgment for unpaid child support ends three years after all children included in the child Support Order have emancipated. To collect the unpaid support, the person owed child support must file a court action to obtain a written judgment for the unpaid amount before the end of the three-year period. (Limited exceptions exist and are found in A.R.S. §25320(B)). Although the obligation to pay support may continue, a child is emancipated: On the date of the child’s marriage On the child’s 18th birthday When the child is adopted When the child dies __________________________ Date 6/26/09 ________________________________________ Judicial Officer Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com