Child Support Order (Mohave County)

For Clerk's Use Only Name of Person Filing: _______________________________________ Mailing Address: _______________________________________ City, State, Zip Code: _______________________________________ Daytime Phone Number: _______________________________________ Evening Phone Number: _______________________________________ ATLAS Number (If Applicable):____________________________________ Representing: Self Petitioner Respondent SUPERIOR COURT OF ARIZONA MOHAVE COUNTY __________________________________ (Name of Petitioner) AND _________________________________________ (Name of Respondent) Case Number:________________ CHILD SUPPORT ORDER A.R.S. § 25-503 THE COURT FINDS THAT: 1. Mother's Name: ____________________________________ Date of Birth: ____________ Social Security # ___________________(*Can be omitted if using the Confidential Sensitive Data Form) Father's Name: _____________________________________ Date of Birth: ___________ Social Security # ___________________(*Can be omitted if using the Confidential Sensitive Data Form) Owe a duty to support the following children: (*Social Security # can be omitted if using the Confidential Sensitive Data Form) Child(ren)'s Name(s) Date of Birth _____________________________________ _______________ _____________________________________ _______________ _____________________________________ _______________ _____________________________________ _______________ _____________________________________ _______________ Social Security # ____________________ ____________________ ____________________ ____________________ ____________________ DO NOT WRITE BELOW THIS LINE. COURT PERSONNEL WILL COMPLETE THE FORM. 2. The required financial factors and any discretionary adjustments pursuant to the Arizona Child Support Guidelines are as set forth in the Parent's Worksheet for Child Support Amount, attached and incorporated by reference. 6/1/2006 Page 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com Case No.______________ 3. Mother Father is obligated to pay support to:________________________________ $_____________________ Per Month In the amount of: 4. Deviation (only in applicable cases) Application of the Arizona Child Support Guidelines in this case is inappropriate or unjust. The Court has considered the best interests of the child(ren) in determining that a deviation is appropriate. The child support amount before deviation is: $________________________ The child support amount after deviation is: $________________________ The Court finds the guidelines amount is inappropriate or unjust because: Attached written agreement incorporated Other Reasons for Deviation from Guideline Amount: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Arrears Child support arrears exist in the amount of: $_________________ For the period of:____________________________ to _________________________________ Past Care and Support A judgment for past care and support should be entered in the amount of: $__________________ For the period of: ___________________________ to _________________________________ IT IS ORDERED THAT: 1. Mother Father shall pay child support in the amount of: $_______________ Per Month, to: ___________________________________________ First payment is due on the 1st day of: ____________________________ 2. Mother Father owes child support arrears in the amount of: $_________________ For the period of:____________________________ to ______________________________ 6/1/2006 Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com Case No.______________ Judgment is ordered in favor of: _________________________________________________ And against: _________________________________________________ In the principal amount of: $________________ Mother Father shall pay $___________________ per month toward child support arrears until paid in full. 3. Mother Father owes past care and support in the amount of: $_______________ For the period of:___________________________ to ______________________________ Judgment is ordered in favor of: ________________________________________________ And against: ________________________________________________ In the principal amount of: $________________ Mother Father shall pay $___________________ per month toward the past care and support amount until paid in full. 4. All payments shall be made through the Support Payment Clearinghouse pursuant to an Order of Assignment signed this date. Any time the full amount of support ordered is not withheld, the person obligated to pay (the obligor) remains responsible for the full monthly amount ordered. Payments not made directly through the Support Payment Clearinghouse shall be considered gifts unless otherwise ordered. All payments shall be made payable to and mailed directly to: Support Payment Clearinghouse P.O. Box 52107 Phoenix, AZ 85072-2107 Payments must include the payor's name, ATLAS number, and Social Security Number. 5. Pursuant to A.R.S. § 25-322, the parties shall submit current address information in writing to the Clerk of the Superior Court and the Support Clearinghouse immediately. The payor shall within 10 days, submit the names and addresses of employers or other persons or organizations from which he or she is entitled to receive payment. 6. The parties shall submit address changes within 10 days of the change. 7. MEDICAL, DENTAL, VISION CARE INSURANCE FOR MINOR CHILDREN Mother is responsible for providing medical dental vision care insurance. Father is responsible for providing medical dental vision care insurance. 8. The costs of medical/dental/vision care expenses not paid by insurance shall be shared as follows: 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 within 45 days after receipt of the request. 6/1/2006 Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com Case No.______________ 9. The costs of travel related to parenting time over 100 miles one way shall be shared as follows: Mother ____________ % Father ____________% 10. The parties shall exchange financial information such as copies of tax returns, earnings st