JDF 1807 R 3 / 18 AFFIDAVIT OF ARREARS PAGE 1 OF 2 District Court County, Colorado Court Address: In Re: Petitioner: Respondent/Co - Petitioner: COURT USE ONLY Attorney or Party Without Attorney (Name and Address) : Phone Number: E - mail: FAX Number: Atty. Reg.#: Case Number: Division Courtroom AFFIDAVIT OF ARREARS I, , declare that: 1. The type of support ordered is child support maintenance other (specify): 2. The amount of support ordered to be paid each month is $ . 3. The support payment has not been timely made and: (check applicable statement) a. (if payments were to be made into the court registry or Family Support Registry) The full payment was not received by the registry on or before the due date of . b. (if payments were to be made to the Obligee directly) I did not receive the full payment on or b efore the due date of . 4. If any modifications have been made to the Support Order complete the following: a. Effective date of any modification: b. Amount of any modification: $ 5. Total child support due ( payments due x $) $ a. Total amount of child support paid - $ b. Total principal of amount of child support due $ c. One twenty - fourth of Line 5b $ + interest at % (12% unless otherwise agreed) 6. Total maintenance due ( payments due x $) American LegalNet, Inc. www.FormsWorkFlow.com JDF 1807 R 3 /1 8 AFFIDAVIT OF ARREARS PAGE 2 OF 2 a. Total amount of maintenance paid - $ b. Total principal amount of maintenance due $ c. One t wenty - fourth of Line 6b $ + interest at % (8% unless otherwise agreed) Attach a copy of the payment record maintained by the Family Support Registry, if payment is ordered through the Family Support Registry, or detail period(s ) on a separate sheet of paper of the time when the arrears accrued for child support and for maintenance. I declare under penalty of perjury that I have read this affidavit and the statements contained are true to the best of my knowledge. By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form. By checking this box, I am acknowledging that I have made a change to the original content of this form. VERIFICATION I declare under penalty of perjury under the law of Colorado that the foregoing is true and correct. Executed on the day of , , at (date) (month) (year) (city or other location, and state OR country (Printed name of Obligee) Signature of Obligee CERTIFICATE OF SERVICE I certify that on (date) the original and a true and accurate copy of the Affidavit of Arrears was served to the COURT : Hand Delivery or Faxed to this number or by placing it in the United States mail, postage pre - paid AND I certify that on(date) a copy of the Affidavit of Arrears was served to the Obligor : Hand Delivery or Faxe d to this number or by placing it in the United States mail, postage pre - paid, and addressed to the following: To: Your Signature American LegalNet, Inc. www.FormsWorkFlow.com