COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state Bar number, and address) or : GOVERNMENTAL AGENCY (under Family Code, §§ 17400, 17406): :
TELEPHONE NO.: EMAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional):
FOR COURT USE ONLY
Index No. Calendar No.
: : : :
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME:
PETITIONER/PLAINTIFF:. ............... RESPONDENT/DEFENDANT:
Defendant(s) : ......................................
OTHER PARENT: THE PEOPLE OF THE STATE OF NEW YORK
DECLARATION OF PAYMENT HISTORY
1. Declaration of (name): 2. Based on my records or my recollection, I declare that the information on the attached pages showing the amounts ordered and the amounts paid are true and correct for the following obligations (check all that apply): a. b. c.
that and each of you attend before , the Honorable 3. Number of pages attached: located at County of in room , on the , 20 at o'clock true and noon, I declare under penalty of perjury under theday of the State of California, that the foregoing is in the correct. and at any recessed laws of or adjourned date, to testify and give evidence as a witness in this action on the part of the
Child support Spousal support WE COMMAND Family support
d. e. YOU, f.
g. Medical support Unreimbursed medical expenses all business and excuses being laid aside, you Unreimbursedthe care expenses at child Court
(SIGNATURE OF DECLARANT) Your (TYPE OR to comply with this subpoena is punishable as a contempt of court and will make you liable to failure PRINT NAME) the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a SUPPORT ARREARAGE SUMMARY result of your failure to comply.
This summary is for arrearage for the periods specified in the attached pages. Interest is calculated through (specify date):
Witness, Honorable Court in County, Principal: day of
$ $ $ $ $ $ $
, one of the Justices of the
Total Arrearage: $ $ $ (Attorney must sign above and type name below) $ $
, 20 Interest (optional):
$ $ $ $ $ $ $
CHILD SUPPORT: SPOUSAL SUPPORT: FAMILY SUPPORT: MEDICAL SUPPORT: UNREIMBURSED MEDICAL EXPENSES: UNREIMBURSED CHILD CARE EXPENSES: OTHER (specify):
NOTICE: Interest that is not calculated is not waived Date: Submitted by:
Office and P.O. Address
(SIGNATURE) Telephone No.: Facsimile No.: Details of the arrearage statement, consisting of (specify number) pages, are attached. Form Adopted for Mandatory Use E-Mail Address: DECLARATION OF PAYMENT HISTORY Judicial Council of California Mobile Tel. No.: FL-420 [Rev. January 1, 2003] (Family Law--Governmental--Uniform Parentage Act) (TYPE OR PRINT NAME)
Page 1 of 1 Family Code, §§ 5230.5, 17524(a), 17526(c) www.courtinfo.ca.gov
American LegalNet, Inc. www.USCourtForms.com