FL-420 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state Bar number, and address) or GOVERNMENTAL AGENCY (under Family Code, §§ 17400, 17406): FOR COURT USE ONLY TELEPHONE NO.: E­MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT: DECLARATION OF PAYMENT HISTORY 1. Declaration of (name): CASE NUMBER: 2. Based on my records or my recollection, I declare that the information on the attached pages showing the amounts ordered and the amounts paid are true and correct for the following obligations (check all that apply): a. b. c. Child support Spousal support Family support d. e. f. Medical support Unreimbursed medical expenses Unreimbursed child care expenses g. Other (specify): 3. Number of pages attached: I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: (TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT) SUPPORT ARREARAGE SUMMARY This summary is for arrearage for the periods specified in the attached pages. Interest is calculated through (specify date): Principal: CHILD SUPPORT: SPOUSAL SUPPORT: FAMILY SUPPORT: MEDICAL SUPPORT: UNREIMBURSED MEDICAL EXPENSES: UNREIMBURSED CHILD CARE EXPENSES: OTHER (specify): $ $ $ $ $ $ $ $ $ $ $ $ $ $ Interest (optional): $ $ $ $ $ $ $ Total Arrearage: NOTICE: Interest that is not calculated is not waived Date: Submitted by: (TYPE OR PRINT NAME) (SIGNATURE) Details of the arrearage statement, consisting of (specify number) Form Adopted for Mandatory Use Judicial Council of California FL-420 [Rev. January 1, 2003] pages, are attached. Page 1 of 1 Family Code, §§ 5230.5, 17524(a), 17526(c) www.courtinfo.ca.gov 2003 © American LegalNet, Inc. DECLARATION OF PAYMENT HISTORY (Family Law--Governmental--Uniform Parentage Act)