REV 6/2018 JCB 1 DEC AND SCHEDULE OF ARREARAGES 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Plaintiff / Petitioner / Joint Petitioner , Defendant / Respondent / Joint Petitioner. Code: 1520 Name: Address: Telephone: Email: Self-Represented Litigant IN THE FAMILY DIVISION OF THE SECOND JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA IN AND FOR THE COUNTY OF WASHOE , Case No. vs. Dept. No. , / DECLARATION AND SCHEDULE OF ARREARAGES Pursuant to the best information known and available to me, the following scheduled accurately sets out the dates and amount of periodic payments due from the other party pursuant to a lawful court order, the dates and amounts of all payments received, and the principal, interests, and penalties due. This document does not contain the personal information of any person as defined by NRS 603A.. I declare under penalty of perjury under the law of the State of Nevada that the foregoing statements are true and correct. Date: Signature: Print Your Name: American LegalNet, Inc. www.FormsWorkFlow.com REV 6/2018 JCB 2 DEC AND SCHEDULE OF ARREARAGES 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Due Date Amount Due Date Payment Received Amount Received Arrears this Period Interest Penalties Example: 1/15/2017 $300 due Paid 1/15/17 $100 paid $200 owed (you must calculate) (you must calculate) Example: 2/15/2017 $300 due Not received $0 paid $300 owed (you must calculate) (you must calculate) Total arrears, interest, and penalties due: $ $ $ If more room is needed, attach additional sheets. American LegalNet, Inc. www.FormsWorkFlow.com