Request To Modify Child Support Pursuant To Guidelines Simplified

(1) Name of Person Filing: Person filing is the: Street Address: City, State, Zip Code: Telephone Number: Email Address: ATLAS Number (if applicable) Representing Self (No Attorney) If Attorney, Bar Number: or Represented by Attorney Petitioner Respondent SUPERIOR COURT OF ARIZONA (2) (3) Name of Petitioner (5) CASE NUMBER: COUNTY DO2 REQUEST TO MODIFY CHILD SUPPORT PURSUANT TO GUIDELINES SIMPLIFIED PROCEDURES (4) Name of Respondent IMPORTANT NOTICE TO PARTY NOT REQUESTING THE MODIFICATION Your support order may be modified if you do not request a hearing. (6) The Petitioner, or (7) Respondent asks this court to modify the Arizona child support order in this case by (8) (Name of judge or commissioner) entered on / / (month / day / year) A. Under the current child support order (9): Mother is responsible for providing Father is responsible for providing Neither party was ordered to provide B. The child support currently in effect requires (10) payments of (11) $ medical medical medical Mother, or the dental dental dental vision care insurance vision care insurance vision care insurance Father to make per month, payable on the day of the month. C. Attached is a Parent's Worksheet for Child Support Amount. According to the worksheet calculations the child support amount should be (12) $ per month. D. The following calculations show that the requested change varies from the current-ordered child support amount by 15% or more. (13) (a) divided by (b) equals (c) a = the difference between the amount currently ordered and the amount requested b = the amount currently ordered; and c = the percentage change % Page 1 of 3 DO_RMCS_COSCPinal_03.25.13 Use only most current version American LegalNet, Inc. www.FormsWorkFlow.com E. Is the Division of Child Support Enforcement (DCSE) providing child support enforcement services for at least Yes No Unknown (If "Yes" is selected, see instructions for providing notice one of the parties? (14) to the State.) F. Other court-ordered payments included in the current Income Withholding Order dated: (15) / / (month/day/year) $ $ $ $ $ 5.00 per per per per per month Current Spousal Maintenance: Payments on Child Support Arrearages/Interest: Payments on Spousal Maintenance Arrearages/Interest Other: Clearinghouse Handling Fee RELIEF REQUESTED OF THIS COURT: 1. I request that child support be ordered in the amount of (16) $____________ per month to be paid by the Mother or the Father, and that relief requested in the Parent's Worksheet be ordered. 2. REGARDING INSURANCE FOR MINOR CHILDREN, order that (17): Mother is responsible for providing medical dental vision care insurance Father is responsible for providing medical dental vision care insurance The costs of medical/dental/vision care expenses not paid by insurance shall be shared as follows: (18) 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 with 45 days after receipt of the request. 3. If this matter goes to hearing, I further request that costs and fees incurred in bringing this action be ordered to be paid by the opposing party. OATH OR AFFIRMATION I affirm the contents of this document are true and correct under penalty of perjury. Date State of Arizona County of ) ) ) Signature SUBSCRIBED AND SWORN TO before me this by Name of Signer day of , 20 Commission Expires Notary Public Page 2 of 3 DO_RMCS_COSCPinal_03.25.13 Use only most current version American LegalNet, Inc. www.FormsWorkFlow.com NOTICE TO PARTIES If you do not agree with the modification, you have twenty days in which to ask for a hearing on the requested modification. If service of process is made outside the State of Arizona, the parent receiving service has 30 days in which to ask for a hearing on the requested modification. Upon proof of service and if no hearing is requested within the time allowed, the court will review the request and enter an appropriate order modifying the support award. If an error is noted the amount awarded may be different from the amount requested, but there will be no greater modification then requested. In the event the court has serious concerns regarding the accuracy of the information, or if a substantial mathematical error is found, the court may set the matter for hearing. If either party requests a hearing within the time allowed, the court shall conduct the hearing. No order shall be modified without a hearing if one is requested. If you wish to request a hearing, you may obtain the flowing forms from the office of the Clerk of the Superior Court. These forms may be in your packet. Request for Hearing and Notice of Hearing Parent's Worksheet for Child Support Amount Page 3 of 3 DO_RMCS_COSCPinal_03.25.13 Use only most current version American LegalNet, Inc. www.FormsWorkFlow.com