Free Affidavit of Direct Payments - Arizona

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Name of Person Filing: ___________________________________________ Mailing Address: ___________________________________________ City, State, and Zip Code: ___________________________________________ Daytime Phone Number: ___________________________________________ Evening Phone Number: ___________________________________________ ATLAS Number (if applicable): ___________________________________________ State Bar Number (if applicable):_________________________________________ Representing: Self Petitioner Respondent

SUPERIOR COURT OF ARIZONA MOHAVE COUNTY
Case Number: (Name of Petitioner)

AFFIDAVIT OF DIRECT PAYMENTS
AND

(Name of Respondent)

COMES NOW _______________________________and swears that the attached foregoing account of direct

payments made by ____________________________ and received by _______________________ is true and (Obligor's Name) (Obligee's Name) correct to the best of his/her knowledge.

Signature of Obligor:_____________________________________

Date:________________________

SUBSCRIBED AND SWORN TO before me on this___________________ day of __________________, _________

My commission Expires:__________________________

__________________________________________ Notary Public / Deputy Clerk

Signature of Obligee:_____________________________________

Date:________________________

SUBSCRIBED AND SWORN TO before me on this___________________ day of __________________, _________

My commission Expires:__________________________

__________________________________________ Notary Public / Deputy Clerk

12/26/2006

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Case No.____________________________

YEAR _____________

YEAR _____________

YEAR _____________

YEAR ____________

AMOUNT PAID JAN _______________ FEB _______________ MAR _______________ APR _______________ MAY _______________ JUN _______________ JUL _______________ AUG _______________ SEP _______________ OCT _______________ NOV _______________ DEC _______________

AMOUNT PAID JAN _______________ FEB _______________ MAR _______________ APR _______________ MAY _______________ JUN _______________ JUL _______________ AUG _______________ SEP _______________ OCT _______________ NOV _______________ DEC _______________

AMOUNT PAID JAN _______________ FEB _______________ MAR _______________ APR _______________ MAY _______________ JUN _______________ JUL _______________ AUG _______________ SEP _______________ OCT _______________ NOV _______________ DEC _______________

AMOUNT PAID FEB _______________ FEB _______________ MAR _______________ APR _______________ MAY _______________ JUN _______________ JUL _______________ AUG _______________ SEP _______________ OCT _______________ NOV _______________ DEC _______________

Obligor's Signature:_____________________________

Obligee's Signature:____________________________

12/26/2006

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