Name: Mailing Address: Daytime Telephone Number: Representing Self, without a Lawyer ARIZONA SUPERIOR COURT IN YAVAPAI COUNTY Case No. Petitioner ATLAS No. Date of Birth (Month, Day, Year) CHILD SUPPORT ORDER A.R.S. §25-503 Respondent Date of Birth (Month, Day, Year) THE COURT FINDS THAT : 1. Mother: and Father: have a duty to support the following children: Child(ren)’s Name(s) Date of Birth DO NOT WRITE BELOW THIS LINE. THE 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 3. Mother Father is obligated to pay support to: In the amount of : $ per month Superior Court of Arizona in Yavapai County September 2007 Page 1 of 4 DRS81f American LegalNet, Inc. www.FormsWorkFlow.com 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 the deviation is appropriate. 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: $ For the period of to IT IS ORDERED THAT: 1. Mother Father shall pay child support in the amount of: $ per month, to: First payment is due on the 1st day of : Superior Court of Arizona in Yavapai County September 2007 Page 2 of 4 DRS81f American LegalNet, Inc. www.FormsWorkFlow.com 2. Mother Father owes child support arrears in the amount of: $ For the period of: to Judgment is ordered in favor of: In the principal amount of: and against $ . Mother Father shall pay $ per month toward child support arrears until paid in full, OR 3. Mother Arrears not addressed. Father owes past care and support 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 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 otherwise ordered by the Court, or by a written Affidavit of Direct Payments signed by all parties to the case and filed with the Clerk of the Court or the Support Payment Clearinghouse. All payments 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. Superior Court of Arizona in Yavapai County September 2007 Page 3 of 4 DRS81f American LegalNet, Inc. www.FormsWorkFlow.com 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 service occurred. The obligated parent must pay or make payment arrangements within 45 days after receipt of the request. 9. The cost of travel related to parenting time over 100 mile one way shall be shared as follows: Mother % Father % 10. The parties shall exchange financial information such as copies of tax returns, earnings statements, as Parent’s Worksheet for Child Support Amount, residential addresses and the names and addresses of their employers 24 months. 11. The courts allocates the federal tax exemption(s) for the dependent child(ren) as follows: Child’s Name Date of Birth (Month, Day Year) For Calendar Year Parent Entitled to deduction Mother Father Mother Father Mother Father Mother Father 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. Each year, the person obligated to make payments (the obligor) may claim these exemptions only if the obligor has paid all child support and arrears ordered for the year by December 31 of that year. 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. Date Superior Court of Arizona in Yavapai County September 2007 Judicial Officer Page 4 of 4 DRS81f American LegalNet, Inc. www.FormsWorkFlow.com