FL-421 PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT: CASE NUMBER: PAYMENT HISTORY FOR (check one): Spousal Child Unreimbursed medical Year AMOUNT ORDERED AMOUNT PAID Family Other (specify): Medical Unreimbursed child care Year AMOUNT PAID AMOUNT ORDERED AMOUNT PAID Year AMOUNT ORDERED January February March April May June July August September October November December TOTAL Year AMOUNT ORDERED AMOUNT PAID Year AMOUNT ORDERED AMOUNT PAID Year AMOUNT ORDERED AMOUNT PAID January February March April May June July August September October November December TOTAL Page 1 of ________ Form Approved for Optional Use Judicial Council of California FL-421 [Rev. July 1, 2003] PAYMENT HISTORY ATTACHMENT (Family Law--Governmental--Uniform Parentage Act) Family Code, §§ 5230.5, 17524 (a), 17526(c) American LegalNet, Inc. www.USCourtForms.com www.courtinfo.ca.gov INSTRUCTIONS FOR COMPLETING PAYMENT RECORD You must complete a separate Payment History Attachment form for each type of support paid. Enter the year, list the amount ordered, and the amount paid for each month during that year. If the amounts repeat in a column, you can use an arrow as shown in the example below. Add the amounts in each column to get the yearly totals. Enter the totals at the bottom. Attach additional sheets and supporting documents (bills, receipts, and other proof of expense) as necessary. x Child Year 2000 AMOUNT ORDERED January February March April May June July August September October November December TOTAL 1,200 600 1,200 400 100 100 100 100 0 100 100 0 100 0 100 AMOUNT PAID 0 Year 2001 AMOUNT ORDERED 100 AMOUNT PAID 100 0 x Spousal AMOUNT ORDERED January 100 AMOUNT PAID 0 February March April May June July August September October November December TOTAL 1,200 600 100 100 100 100 0 UNREIMBURSED CHILD CARE, MEDICAL, OR OTHER EXPENSES: You must complete a separate Payment History Attachment form for each type of unreimbursed expense. If you have more than one bill, receipt, and other proof of expense per month use an additional declaration page (form MC-031) or separate page. 1.) Itemize each expense; 2.) attach proof of bill or payment; 3.) mark each bill or payment with an Exhibit # _____; 4.) group the bills, receipts, and other proof of expense in chronological order for each month; and 5.) enter the total bills, receipts, and other proof of expense for each month. If your court order did not state a specific due date for reimbursement, then include that amount in the month that the expense was incurred. x Unreimbursed child care expenses x Unreimbursed medical expenses Year 2001 AMOUNT ORDERED January February March April May June July August September October November December TOTAL $400 150 50% ($200) 50% ($200) 50% ($200) 50% ($200) AMOUNT PAID 0 100 0 50 January February March April May June July August September October November December TOTAL Year 2001 AMOUNT ORDERED 50% ($200) AMOUNT PAID 0 Form MC-031 Petitioner/Plaintiff Defendant/Respondent CASE NUMBER I request reimbursement for 50% of these expenses, which are supported by copies of bills, receipts, and other proof of expense. 01/04/01 01/08/01 02/15/01 04/26/01 Dr. Adams Dr. Lee, D.D.S. AB X-ray Inc. Kids Therapy $45.00 $155.00 $200.00 $75.00 Exhibit A Exhibit B Exhibit C Exhibit D 50% ($200) 50% ($75) 0 0 Child care expenses: 01/02 ABC School 02/02 ABC School 03/02 ABC School 04/02 ABC School 50% ($200) 50% ($200) 50% ($200) 50% ($200) Exhibit E I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. ........................... (TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT) $237.50 0 Form MC-031 ATTACHED DECLARATION FL-421 [Rev. July 1, 2003] PAYMENT HISTORY ATTACHMENT (Family Law--Governmental--Uniform Parentage Act) American LegalNet, Inc. www.USCourtForms.com