Free FL-420 DECLARATION OF PAYMENT HISTORY (Family Law--Governmental--Uniform Parentage Act) - California

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):

FL-420
FOR COURT USE ONLY

Index No. Calendar No.

Plaintiff(s)

: : : :

JUDICIAL SUBPOENA

-against-

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

CASE NUMBER:

TO
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.

GREETINGS:

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
Date:

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

Other (specify):

(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):

Attorney(s) for

$ $

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