(1) Name of Person Filing: Street Address: City, State, Zip Code: Telephone Number: Email Address: ATLAS Number (if applicable) Representing Self (No Attorney) If Attorney, Bar Number: or Represented by Attorney SUPERIOR COURT OF ARIZONA (2)PINAL COUNTY Regarding the Matter of (3) Name of Petitioner (in original case) CASE NUMBER: (5) PETITION TO MODIFY ORDER OF ASSIGNMENT/INCOME WITHHOLDING ORDER A.R.S. § 25-504 (4) Name of Respondent (in original case) HONORABLE: An Order of Assignment/Income Withholding Order is a court order that requires an employer to withhold money from the Person ordered to pay child support and /or spousal maintenance (alimony) , ask the court to modify the Order of Assignment/Income Withholding Order (Order requiring an employer or other party to withhold funds for child support or spousal maintenance) in which: (6)I (7) (8) Is the person ordered to make payments, and Is the person entitled to receive payments. (9) (9) (9) (9) Issued this date: Issued by this Court: Located in this County: Located in this State: (month / day / year) (Name of Court) (Name of County) (Name of State) Page 1 of 3 DO_PMOA_COSCPinal_01.29.13 Use only most current version American LegalNet, Inc. www.FormsWorkFlow.com Because: (10) (Check the appropriate box(s)) The amount shown on the Order of Assignment/Income Withholding Order is wrong because: The amount was changed by the Court Order issued on this date: . in this county: , OR 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 OR Financial situation have changed: Reason(s) (List and attach any supporting documents). (11)For the reason listed, I REQUEST THAT the amount in the Order of Assignment/Income Withholding Order should be changed from the current amount of: Spousal $ $ Current Child Support / Arrearages to the New Amount of: $ Current Support or Arrearages (12)The current Order of Assignment/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 Order of Assignment/Income Withholding Order: (month / day / year) To the new date of: (month / day/ year) Reason(s) why the presumptive date is wrong (list and attach any supporting documents) Page 2 of 3 DO_PMOA_COSCPinal_01.29.13 Use only most current version American LegalNet, Inc. www.FormsWorkFlow.com (13) OATH OR AFFIRMATION I swear or affirm that the information on this document is true and correct to the best of my knowledge Date State of Arizona County of ) ) ) day of Signature SUBSCRIBED AND SWORN TO before me this by Name of Signer , 20 Commission Expires Notary Public NOTICE TO THE PARTY SERVED WITH THIS PETITION. If you do not agree with the Petition, you have twenty, (20) days, or thirty (30) days if service is made outside the state of Arizona, in which to respond by completing the attached petition for hearing. If requested, a hearing will be set. If you do not request a hearing in writing within the time allowed, the Court will review the Petition to Modify Order of Assignment/Income Withholding Order and grant the request, if appropriate. Page 3 of 3 DO_PMOA_COSCPinal_01.29.13 Use only most current version American LegalNet, Inc. www.FormsWorkFlow.com