Free FL-421 PAYMENT HISTORY ATTACHMENT (Family Law--Governmental--Uniform Parentage Act) - California

FL-421
PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT:
CASE NUMBER:

PAYMENT HISTORY FOR (check one): Spousal Child Unreimbursed medical Year
AMOUNT ORDERED

Family Other (specify):

Medical

Unreimbursed child care Year
AMOUNT ORDERED AMOUNT PAID

Year
AMOUNT AMOUNT AMOUNT COURT ORDERED PAID COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PAID . . . ......... .. .... :

Index No. Calendar No.

January February March April May June July August September October November December TOTAL

: Plaintiff(s) -against: : : : Defendant(s) : ......................................................

JUDICIAL SUBPOENA

THE PEOPLE OF THE STATE OF NEW YORK TO

GREETINGS:

Year Year WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court AMOUNT AMOUNT County of AMOUNT located at AMOUNT AMOUNT AMOUNT ORDERED PAID, on the ORDERED in room ORDERED noon, and at PAID day of , 20 PAID , at o'clock in the any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the
January February March April May June July August September October November December TOTAL
(Attorney must sign above and type name below)

Year

Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable County, , one of the Justices of the day of , 20

Court in

Attorney(s) for

Office and P.O. Address

Form Approved for Optional Use Judicial Council of California FL-421 [Rev. July 1, 2003]

Telephone No.: Facsimile No.: PAYMENT HISTORY ATTACHMENT E-Mail Address: Mobile Tel. (Family Law--Governmental--Uniform Parentage Act) No.:

Page 1 of ________ Family Code, §§ 5230.5, 17524 (a), 17526(c)

www.courtinfo.ca.gov
American LegalNet, Inc. www.USCourtForms.com

INSTRUCTIONS FOR COMPLETING PAYMENT RECORD You must complete a separate Payment History Attachment form for each type of support paid. Enter the year, list the amount ordered, and the amount paid for each month during that year. If the amounts repeat in a column, you can use an arrow as shown in the example below. Add the amounts in each column to get the yearly totals. Enter the totals at the bottom. Attach additional sheets and supporting documents (bills, receipts, and other proof of expense) as necessary. x Child Year 2000
AMOUNT ORDERED January February March April May June July August September October November December TOTAL 1,200 600 1,200 400 100 100 100 100 0 100 100 0 100 0 100 AMOUNT PAID 0

Year 2001
AMOUNT ORDERED 100 AMOUNT PAID 100 0

x

Spousal
AMOUNT ORDERED January 100 AMOUNT PAID 0

February March April May June July August September October November December TOTAL 1,200 600 100 100 100 100 0

UNREIMBURSED CHILD CARE, MEDICAL, OR OTHER EXPENSES:
You must complete a separate Payment History Attachment form for each type of unreimbursed expense. If you have more than one bill, receipt, and other proof of expense per month use an additional declaration page (form MC-031) or separate page. 1.) Itemize each expense; 2.) attach proof of bill or payment; 3.) mark each bill or payment with an Exhibit # _____; 4.) group the bills, receipts, and other proof of expense in chronological order for each month; and 5.) enter the total bills, receipts, and other proof of expense for each month. If your court order did not state a specific due date for reimbursement, then include that amount in the month that the expense was incurred.

x

Unreimbursed child care expenses

x

Unreimbursed medical expenses

Year 2001
AMOUNT ORDERED January February March April May June July August September October November December TOTAL $400 150 50% ($200) 50% ($200) 50% ($200) 50% ($200) AMOUNT PAID 0 100 0 50 January February March April May June July August September October November December TOTAL

Year 2001
AMOUNT ORDERED 50% ($200) AMOUNT PAID 0

Form MC-031
Petitioner/Plaintiff Defendant/Respondent
CASE NUMBER

I request reimbursement for 50% of these expenses, which are supported by copies of bills, receipts, and other proof of expense. 01/04/01 01/08/01 02/15/01 04/26/01 Dr. Adams Dr. Lee, D.D.S. AB X-ray Inc. Kids Therapy $45.00 $155.00 $200.00 $75.00 Exhibit A Exhibit B Exhibit C Exhibit D

50% ($200) 50% ($75)

0 0

Child care expenses: 01/02 ABC School 02/02 ABC School 03/02 ABC School 04/02 ABC School

50% ($200) 50% ($200) 50% ($200) 50% ($200)

Exhibit E

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
........................... (TYPE OR PRINT NAME)

(SIGNATURE OF DECLARANT)

$237.50

0

Form MC-031

ATTACHED DECLARATION

FL-421 [Rev. July 1, 2003]

PAYMENT HISTORY ATTACHMENT (Family Law--Governmental--Uniform Parentage Act)