ARIZONA SUPERIOR COURT IN COUNTY Case No. Petitioner ATLAS No. Date of Birth (Month, Date, Year) CHILD SUPPORT ORDER Respondent A.R.S. § 25-503 Date of Birth (Month, Date, Year) THE COURT FINDS THAT: 1. Mother: and Father: owe 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. CS Order September 2006 Page 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com Case No. 3. Mother 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. 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: $ Interest Interest in the amount of: $ For the period of: to to Past Care and Support A judgment for past care and support should be entered in the amount of: $ For the period of: to CS Order September 2006 Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com Case No. 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: 2. Mother 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: $ Case No. Mother Father shall pay $ arrears until paid in full, OR Arrears not addressed. 3. Mother per month toward child support 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 $ the past care and support amount until paid in full, OR Past care and support not addressed. per month toward 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 shall be considered gifts 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 CS Order September 2006 Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com Case No. 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 (Month, Day, Parent Entitled Year) Child’s Name to Deduction Mother Mother Mother Mother For Calendar Year Father Father Father 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 Judicial Officer CS Order September 2006 Page 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com CHILD SUPPORT ORDER INSTRUCTIONS An automated child support calculator is available on the Supreme Court’s website at http://www.supreme.state.az.us/childsup.htm. Assuming your computer is connected to a printer, the online calculator will provide you with a printout that you may use in place of this form. COMPLETE THIS FORM IF: • You are a party to a court action to establish a child support obligation or to modify an existing order for child support. DEFINITIONS • Custodial Parent – The parent designated by the court as having physical custody of the child(ren) or if a custody order has not been established, the parent with whom the child lives with most of the time. • Non-custodial Parent - The parent that has not been granted physical custody of the child(ren) or if a custody order has not been established, the parent who is not the primary caretaker of the child(ren). • Physical Custody - Rights and responsibilities to determine where the child lives and who cares for the child. HOW TO COMPLETE THIS FORM: TYPE OR PRINT NEATLY USING BLACK INK. Match each numbered item in the instructions with the same numbered item on the Child Support Order. (1) (2) (3) (4) (5) (6) (7) Type or print the name of the county in which this Child Support Order is being filed. Type or print the first, middle and last name and date of birth of the person shown as the Petitioner/Plaintiff on the original petition to establish support or on the Order that established support. Type or print the first, middle and last name and date of birth of the person shown as the Respondent/Defendant on the original petition to establish support or on the Order that established support. Type or print the case number assigned to your case. If you do not have a case number, leave this item blank. Type or print the ATLAS number, if one has been assigned to your case; otherwise leave this item blank. Type or print the first, middle and last name of the mother of the child(ren). Type or print the first, middle and last name of the father of the child(ren). Type or print the first, middle and last name and date of birth of each child for whom support is being requested. The Judicial Officer or Clerk of the Superior Court will complete the remaining items, date and sign the order. WHEN YOU HAVE COMPLETED THE CHILD SUPPORT ORDER: W INST: CS ORDER09/21/06 Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com