Fill - CHILD SUPPORT PETITION TO MODIFY (STANDARD PROCESS) (Maricopa County Telecommunications)

DRMCS1 –

5176 - 010122

PETITION TO MODIFY

CHILD SUPPORT

(STANDARD PROCESS)

1

To Change an Existing Court Order

Due to Continuing Change in Circumstances

(Standard Process)

Part 1: Filing the Court Papers

(Instructions and Forms)

Law Library Resource Center

REQUEST TO MODIFY A CHILD SUPPORT ORDER

(Standard Process)

Forms and Instructions

CHECKLIST

YOU MAY USE THE FORMS and instructions in this packet if . . .



You have a child support order from Maricopa County and believe the amount of

child support should be changed because there has been a substantial and

continuing change in your circumstances.

DO NOT USE THESE FORMS:

✘ To change spousal maintenance (alimony);

✘ To change the amount owed for back child support (arrears).

✘ If your order is from a court outside this county (unless an attorney has

advised you to);

✘ If the reason you are requesting the change is because the living

arrangements of the minor child(ren) have changed but the court order about

custody and parenting time has not (in which case you may need to file to

modify or to legally establish CUSTODY).

WARNING: If the order you want to change is not from this county, ask a lawyer

about the requirements to file your Petition (Request) with this Court.

READ ME: Consulting a lawyer before filing documents with the court may help

prevent unexpected results. A list of lawyers you may hire to advise you on handling

your own case or to perform specific tasks, as well as a list of court-approved mediators

can be found on the Law Library Resource Center website.

Law Library Resource Center

Modify child support due to continuing change in circumstances

(Standard Process)

Part 1: Filing the court papers

This packet contains court forms and instructions to file a Petition to Modify a Court Order

for Child Support - Standard Process. Items in bold are forms that you will need to file with

the Court. Non-bold items are instructions or procedures. Do not copy or file those pages!

Order File Number Title

#

Pages

1 DRMCS1k Checklist: You may use these forms if . . . 1

2 DRMCS1t Table of Contents (this page) 1

3 DRMCS11i

Help to complete the Petition to Modify Child

Support-Standard Process

2

4 DRMCS12p Procedures: What to do Next 3

5 DRMCS11f

Petition to Modify a Child Support Order (Standard

Process)

3

There are two copies of the Affidavit of Financial Information (AFI) in this packet: one

for you to fill out and file with the Court, and an extra that you must serve on the other

party.

6

DROSC13f

Affidavit of Financial Information (AFI) (for you)

12

7

DROSC13f

Affidavit of Financial Information (AFI)*

* Leave this copy BLANK for the other party to fill

out.

12

8

DRS88f

Current Employer Information Sheet

1

The documents you have received are copyrighted by the Superior Court of Arizona in

Maricopa County. You have permission to use them for any lawful purpose. These forms

shall not be used to engage in the unauthorized practice of law. The Court assumes no

responsibility and accepts no liability for actions taken by users of these documents,

including reliance on their contents. The documents are under continual revision and are

current only for the day they were received. It is strongly recommended that you verify on

a regular basis that you have the most current documents.

Law Library Resource Center

Instructions: How to complete the Petition to modify (change) a

child support order (Standard Process)

To complete this form you will need:

 A copy of your current child support order.

 A completed Affidavit of Financial Information.

 While not required, it will be useful to have a new Child Support Worksheet

completed.

Fees to file: There are fees for filing petitions, responses, requests, motions, objections, and

various forms with the Court. Cash, AMEX/VISA/MasterCard debit or credit cards,

or money order made payable to the “Clerk of Superior Court” are acceptable forms

of payment.

Go online to http://clerkofcourt.maricopa.gov/fees.asp

or the Law Library Resource

Center for a list of current fees.

If you cannot afford the filing fee and/or the fee for having the papers served by the

Sheriff or by publication, you may request a deferral (payment plan) when you file

your papers with the Clerk of Superior Court. Deferral Applications are available at

no charge from the Law Library Resource Center.

Instructions: The letters next to the paragraphs below correspond to the letters in the Petition.

Match the letter in front of the instruction below to the letter in the Petition. Write

clearly. Use black ink.

(A) Fill in the information requested at top left for the person who is filing this form. If there is

a current court order declaring your address is protected, write “protected” on the line

provided for your address. Make sure the Clerk of Superior Court has valid contact

information on file.) Write the ATLAS number if you have one. The spaces marked

“representing” and “state bar number” are used only if an attorney is preparing this form.

(B) Fill in the section where it says Name of Petitioner/Party A and Name of Respondent/Party

B, exactly as it appears on your original Divorce, Paternity, or Child Support and/or Spousal

Maintenance papers. If your original case was a Paternity case, remember that the Plaintiff

is now called the Petitioner or Party A and the Defendant is now called the Respondent or

Party B. If this is the first court case you are filing in Maricopa County, write in your name

as Petitioner/Party A, and the other party as Respondent/Party B.

(C) Fill in your Maricopa County Superior Court case number.

1, 2. Information about the Petitioner/Party A and Respondent/Party B. Fill in the information

requested about the Petitioner/Party A and Respondent/Party B. If you were the Petitioner or

Plaintiff in the original case, put your information in the spaces provided for the Petitioner.

If not, put the information about the other party here and your information in the spaces

provided for the Respondent.

3. Information about the current support order I want to change. Fill in the information about

your current Child Support.

You must also attach to the Petition, a copy of the Child Support Worksheet from the Order

you want to change, if available. A copy should be available in the court records.

4. Information about other court cases to change this court order involving the Petitioner/Party

A and the Respondent/Party B. Check each box if true. If either party has filed to modify or

enforce this Order, complete the information about the case(s). If you have any current

modification cases pending in any court, you cannot file this Petition unless you talk to an

attorney and the attorney tells you that you can do it.

5. Department of Economic Security. If you receive services from the Child Support

Enforcement Administration (DCSE) or you know the other party does, mark the box “yes.”

Otherwise, mark the box “no.” If you do not know, mark the box for “unknown.”

6. I am entitled to have child support changed for the following reasons: Describe the reasons

and the substantial and continuing change in your circumstances that require a change in

child support.

7. Amount of child support: Based on the reasons stated in (6) above, write in the (new) amount

you want the Court to order for child support and the payment period. It would be helpful to

know what the Guideline Child Support would be, so it is suggested you complete a Child

Support Worksheet to prepare this Petition. You can complete a Worksheet at this website:

ezCourtForms (http://www.superiorcourt.maricopa.gov/ezcourtforms2/

)

Date and sign. You must sign in front of a notary or a Clerk of Superior Court. The Clerk of Superior

Court will do this for free when you file your papers. By signing, you are stating that the information

you have provided on this document is true and correct to the best of your knowledge – under

penalty of perjury.

Law Library Resource Center

Procedures: What to do after you have completed the “Petition to Modify

Child Support” – Standard process

1. After you have completed the “Petition to Modify”, complete the:

 “Affidavit of Financial Information (AFI).” There are two AFI included this packet. Fill out one and

leave the blank copy for the other party to complete.

 “Current Employer Information Sheet”

 Attach to the Petition the “Child Support Worksheet” that supports your existing child support

order.

2. Make three (3) copies (4, IF DES/DCSE is involved*) of the:

 “Petition to Modify Child Support” – Standard Process, with the attached “Child Support

Worksheet” from Order you wish to modify

 “Affidavit of Financial Information” (completed by you)

3. Separate your papers into 4 sets (5, if DES / DCSE is involved).

Set 1 - Originals for Clerk of Superior Court

• “Petition to Modify” with attached “Child

Support Worksheet” from order you wish to

change

• “Affidavit of Financial Information”

• “Current Employer Information Sheet”

SET 2 - For Family Department

• “Petition to Modify” with attached “Child

Support Worksheet” from order you wish to

change (copies)

• “Affidavit of Financial Information”

SET 3 - Copies for other party

• “Petition to Modify” with attached “Child

Support Worksheet” from order you wish to

change

• “Affidavit of Financial Information” **

SET 4 - Copies for you

• “Petition to Modify” with attached “Child

Support Worksheet” from order you wish to

change

• “Affidavit of Financial Information”

SET 5 - Copies for the Attorney General (“the AG”) (only if DES or DCSE is involved) *

 “Petition to Modify” with attached “Child Support Worksheet” from order you wish

to change

 “Affidavit of Financial Information”

* For more information on when and how to serve notice on the AG, see (7) on next page.

** Add a blank AFI to the set of papers served on the other party as stated in (7) on next page.

4. File the papers at the Court:

Go to the Clerk of Superior Court’s filing counter: Hand the originals and all sets of copies to the Clerk.

The Clerk of Superior Court will keep the originals, stamp and return the extra copies to you. The

stamp shows they are copies of papers filed with the Court (and are now called "conformed" copies).

You may file your papers from 8am to 5pm, Monday through Friday, at these Superior Court locations:

Central Court Building

201 West Jefferson, 1st floor

Phoenix, Arizona 85003

Southeast Court Complex

222 East Javelina Avenue, 1st floor

Mesa, Arizona 85210

Northwest Court Complex

14264 West Tierra Buena Lane

Surprise, Arizona 85374

Northeast Court Complex

18380 North 40

th

Street

Phoenix, Arizona 85032

FEES: There are fees for filing petitions, responses, requests, motions, objections, and various forms

with the Court. Cash, AMEX/VISA/MasterCard debit or credit cards, or money order made payable to

the “Clerk of Superior Court” are acceptable forms of payment. A list of current fees is available from

the Law Library Resource Center website or from the Clerk of Superior Court’s website.

If you cannot afford the filing fee and/or the fee for having the papers served by the Sheriff or by

publication, you may request a deferral (payment plan) when you file your papers with the Clerk of

Superior Court. Deferral Applications are available at no charge from the Law Library Resource

Center.

5. Go to the Family Department

Central Court Building

201 West Jefferson, 3rd floor

Phoenix, Arizona 85003

Southeast Court Complex

222 East Javelina Avenue, Suite 1300

Mesa, Arizona

85210

Northwest Court Complex

14264 West Tierra Buena Lane

Surprise, Arizona 85374

Northeast Court Complex

18380 North 40

th

Street

Phoenix, Arizona 85032

Deliver set 2 of the Clerk-stamped copies and pick up an “Order to Appear.”

6. The Family Department will schedule a conference and hearing. You and the other party will meet

with a conference officer to talk about the case to try to reach agreement. For those matters on which

you are unable to reach full agreement, a hearing will be held just after your conference to decide the

case.

The date, time, and location of the conference/hearing are on the “Order to Appear.” Make 1 copy of

the “Order to Appear,” or if the State of Arizona is involved, make 2.

The State of Arizona may be involved if any parent received public assistance for the

children or used the services of the State in establishing or collecting child support. If

the State is involved, notice of this action must also be given to the Attorney General’s

Office as described in 7, below

7. Serve the papers on the other party (or parties): You must arrange for service of the papers on the

other party (or parties). You must make good faith efforts to complete service promptly and within 10

days after receipt of the issued “Order to Appear.” You must complete service no later than 20 days

before the hearing

 Serve the original “Order to Appear” along with Set 3 of the other papers on the other party, and

include a blank AFI for the other party to fill out.



 The papers may be delivered by the Sheriff’s Department, a licensed private process server,

commercial delivery service or mail by which you can obtain an original or copy of the other party’s

signature confirming delivery, or by “Acceptance of Service” as described in the “SERVICE” packet

available from the Law Library Resource Center or its website.

If DES or DCSE is involved:

• Serve a copy of the Order to Appear along with Set 5 of the other papers on the Attorney General’s

Office.

• NOTE: You must keep the AG’s office informed. You cannot complete this change to child support

without the AG’s approval and signature on the Final Court Order.

SERVING PAPERS ON THE STATE: (if required). The Office of the Attorney General (the “AG”) will

accept service by signing an “Acceptance of Service” form and returning the form for you to file with

the Court. There are no court fees for serving the State with an Acceptance, as described below:

(a) You may mail or personally deliver to the Office of the Attorney General (the “AG”) assigned to

your case*:

 a copy of the “Petition to Modify,” your “Affidavit of Financial Information” along with

 an “Acceptance of Service” AND

 a self-addressed, stamped envelope (addressed back to you).

(b) There may also be a “drop-box” in the Clerk of Superior Court’s filing counter area at which you

may leave the above listed documents and the envelope for the AG. Ask the Clerk of Superior

Court at the filing counter, OR

(c) You may mail the documents and the self-addressed stamped envelope to:

Office of the Attorney General

Child Support Services Section

2005 N. Central Avenue – Mail Drop 7611

Phoenix, AZ 85004-2926

Note: The State is not considered served until

the AG’s signed Acceptance of Service is

filed with the Court!

8. Go to the court conference/hearing. Be on time. Do not bring children to court. Dress neatly. Be prepared

to tell the Judge why the court order should be changed. Bring the following to the hearing:

 A copy of the “Petition to Modify Child Support” with attached “Child Support Worksheet” from order

you wish to change

 An “Affidavit of Financial Information” completed by you

MCS

Person Filing: (A)

Address (if not protected):

City, State, Zip Code:

Telephone:

Email Address:

ATLAS Number:

Lawyer’s Bar Number:

Representing Self, without a Lawyer or Attorney for Petitioner OR Respondent

SUPERIOR COURT OF ARIZONA

IN MARICOPA COUNTY

(B)

Case No.

(C)

Name of Petitioner / Party A

and

ATLAS No.

(C)

(B)

PETITION TO MODIFY A

CHILD SUPPORT ORDER

(Standard Process)

Name of Respondent / Party B

1. INFORMATION ABOUT PARTY A:

Name:

Address:

City, State, Zip Code:

County of Residence:

Date of Birth:

Job Title:

2. INFORMATION ABOUT PARTY B:

Name:

Address:

City, State, Zip Code:

County of Residence:

Date of Birth:

Job Title:

FOR CLERK’S USE ONLY

Case No.

3. INFORMATION ABOUT THE CURRENT CHILD SUPPORT ORDER:

(the Order I want to CHANGE)

The Order was issued on:

(Month/Day/Year)

The Order was issued by:

(Name of Court)

Located in this County:

Name of Person ordered to pay:

Total Current Amount Ordered Paid:

$

PER

The current total court-ordered support payment listed above consists of:

Child Support $ per

Spousal Maintenance/Support $ per

Other (i.e. Clearinghouse fee): $ per

Payments in Arrears: $ per

The order I wish to change is on page , section/paragraph of the

Order identified above. The Order is either in the official file of this Court or attached.

You must attach to this Petition a copy of the Child Support Worksheet for the Order you

want to change, if available.

4. INFORMATION ABOUT OTHER COURT CASES TO ENFORCE OR CHANGE

THIS COURT ORDER INVOLVING THE PETITIONER AND THE

RESPONDENT: (check each box if true)

No other cases are pending in any court for modification of this court order. (This

must be a true statement for this Court to hear your request.)

 

Neither party has previously filed to enforce or modify this court order.

One or both parties has filed for enforcement or modification of this court order in

the past. Information about the case(s) is below. Use additional paper if

necessary.

Names of Parties:

Date of order, judgment, decree:

Explain what order or judgment said:

Court Case Number:

Location of court (city and county):

Case No.

List type of Case: (modification or enforcement of legal decision making or

physical custody, parenting time or support, etc.). Explain:

There must be a substantial and continuing change in circumstances before you can ask

the court to change the current child support order.

5. DEPARTMENT OF ECONOMIC SECURITY (DES). Is the Division of Child Support

Enforcement (DCSE) providing Child Support Services to at least one of the parties?

Yes (If yes, see instructions.) No Unknown.

6. I AM ENTITLED TO HAVE CHILD SUPPORT CHANGED FOR THE

FOLLOWING REASONS: (Describe the substantial and continuing change in your

circumstances and reasons for the change of child support.)

7. For the substantial and continuing reasons listed in “6” above, the amount of the

child support obligation should be changed to:

Payments of $

PER

.

UNDER OATH OR AFFIRMATION

I swear or affirm under penalty of perjury that the contents of this document are true and correct to the

best of my knowledge and belief.

Date Signature

STATE OF

COUNTY OF

Subscribed and sworn to or affirmed before me this:

(date)

by .

(notary seal) Deputy Clerk or Notary Public

Person Filing:

Address (if not protected):

City, State, Zip Code:

Telephone:

Email Address:

ATLAS Number:

Lawyer’s Bar Number:

Representing Self, without a Lawyer or Attorney for Petitioner OR Respondent

SUPERIOR COURT OF ARIZONA

IN MARICOPA COUNTY

Case No.

Petitioner / Party A ATLAS No.

AFFIDAVIT OF FINANCIAL

INFORMATION

Respondent / Party B Affidavit of

(Name of Person Whose Information is on this

Affidavit)

IMPORTANT INFORMATION ABOUT THIS DOCUMENT

WARNING TO BOTH PARTIES: This Affidavit is an important document. You must fill out this Affidavit

completely, and provide accurate information. You must provide copies of this Affidavit and all other required

documents to the other party and to the judge. If you do not do this, the court may order you to pay a fine.

I have read the following document and know of my own knowledge that the facts and financial information

stated below are true and correct, and that any false information may constitute perjury by me I also

understand that, if I fail to provide the required information or give misinformation, the judge may order

sanctions against me, including assessment of fees for fines under Rule 26, Arizona Rules of Family Law

Procedure.

Date Signature of Person Making Affidavit

FOR CLERK’S USE ONLY

AFI 5920

Case No. _________________

1. GENERAL INFORMATION:

A. Name: Date of Birth:

B. Current Address:

C. Date of Marriage: Date of Divorce:

D. Last date when you and the other party lived together:

E. Full names of child(ren) common to the parties (in this case), their dates of birth:

Name D

ate of Birth

F. The name, date of birth, relationship to you, and gross monthly income for each individual who

lives in your household:

Name Date of Birth Relationship to you Income

INSTRUCTIONS

1. Complete the entire Affidavit in black ink. If the spaces provided on this form are inadequate,

use separate sheets of paper to complete the answers and attach them to the Affidavit. Answer

every question completely! You must complete every blank. If you do not know the answer to a

question or are guessing, please state that. If a question does not apply, write “NA” for “no

t

a

pplicable” to indicate you read the question. Round all amounts of money to the nearest dollar.

2. Answer the following statements YES or NO. If you mark NO, explain your answer on a separate piece

of paper and attach the explanation to the Affidavit.

[ ] YES [ ] NO 1. I listed all sources of my income.

[ ] YES [ ] NO 2. I attached copies of my two (2) most recent pay stubs.

[ ] YES [ ] NO 3. I attached copies of my federal income tax return for the last three (3) years,

and I attached my W-2 and 1099 forms from all sources of income.

5920

Case No. _________________

G. Any other person for whom you contribute support:

N

ame Age Relationship Reside With Court Order to

to You You (Y/N) Support (Y/N)

H. Attorney’s Fees paid in this matter $ . Source of funds

2. E

MPLOYMENT INFORMATION:

A. Your job/occupation/profession/title:

Name and address of current employer:

Date employment began:

How often are you paid: [ ] Weekly [ ] Every other week [ ] Monthly [ ] Twice a month

[ ] Other

B. If you are not working, why not?

C. Previous employer name and address:

Previous job/occupation/profession/title:

Date previous job began: Date previous job ended:

Reason you left job:

Gross monthly pay at previous job: $

D. Total gross income from last three (3) years’ tax returns (attach copies of pages 1 and 2 of your

federal income tax returns for the last three (3) years):

Year $ Year $ Year $

E. Your total gross income from January 1 of this year to the date of this Affidavit (year-to-date

income): $

5920

Case No. _________________

3. YOUR EDUCATION/TRAINING: List name of school, length of time there, year of last attendance,

and degree earned:

A. High School:

B. College:

C. Post-Graduate:

D. Occupational Training:

4. YOUR GROSS MONTHLY INCOME:

• List all income you receive from any source, whether private or governmental, taxable or not.

• List all income payable to you individually or payable jointly to you and your spouse.

• Use a monthly average for items that vary from month to month.

• Multiply weekly income and deductions by 4.33. Multiply biweekly income by 2.165 to arrive at

the total amount for the month.

A. Gross salary/wages per month $

• Attach copies of your two most recent pay stubs.

Rate of Pay $ per [ ] hour [ ] week [ ] month [ ] year

B. Expenses paid for by your employer:

1. Automobile $

2. Auto expenses, such as gas, repairs, insurance $

3. Lodging $

4. Other (Explain) $

C. Commissions/Bonuses $

D. Tips $

E. Self-employment Income (See below) $

F. Social Security benefits $

G. Worker's compensation and/or disability income $

H. Unemployment compensation $

I. Gifts/Prizes $

5920

Case No. _________________

J. Payments from prior spouse $

K. Rental income (net after expenses) $

L. Contributions to household living expense by others $

M. Other (Explain:) $

(Include dividends, pensions, interest, trust income, annuities or royalties.)

TOTAL: $

5. SEL

F-EMPLOYMENT INCOME (if applicable):

If you are self-employed, attach of a copy of the Schedule C for your business from your last tax

return and the most recent income/expense statement from your business.

If self-employed, provide the following information:

Name, address and telephone no. of business:

Type of business entity:

State and Date of incorporation:

Nature of your interest:

Nature of business:

Percent ownership:

Number of shares of stock:

Total issued and outstanding shares:

Gross sales/revenue last 12 months:

INSTRUCTIONS

Both parties must answer item 6 if either party asks for child support. These expenses include only those

expenses for children who are common to the parties, which mean one party is the birth/adoptive mother and

the other is the birth/adoptive father of the children

.

5920

Case No. _________________

6. SCHEDULE OF ALL MONTHLY EXPENSES FOR CHILDREN:

• DO NOT LIST any expenses for the other party, or child(ren) who live(s) with the other party,

unless you are paying those expenses.

• Use a monthly average for items that vary from month to month.

• If you are listing anticipated expenses, indicate this by putting an asterisk (*) next to the

estimated amount.

A. HEALTH INSURANCE:

Do you have health insurance available? Yes No Are you enrolled?_________

1. Total monthly cost $

2. Premium cost to insure you alone $

3. Premium cost to insure child(ren) common to the parties $

4. List all people covered by your insurance coverage:

5. Name of insurance company and Policy/Group Number:

B. DENTAL/VISION INSURANCE:

1. Total monthly cost $

2. Premium cost to insure you alone $

3. Premium cost to insure child(ren) common to the parties $

4. List all people covered by your insurance coverage:

5. Name of insurance company and Policy/Group Number:

5920

Case No. _________________

C. UNREIMBURSED MEDICAL AND DENTAL EXPENSES:

(Cost to you after, or in addition to, any insurance reimbursement)

1. Drugs and medical supplies $

2. Other $

TOTAL: $

D. CHILD CARE COSTS:

1. Total monthly child care costs $

(Do not include amounts paid by D.E.S.)

2. Name(s) of child(ren) cared for and amount per child:

$

3. Name(s) and address(es) of child care provider(s):

E. EMPLOYER PRETAX PROGRAM:

Do you participate in an employer program for pretax payment of child care expenses?

(Cafeteria Plan)? [ ] YES [ ] NO

F. COURT ORDERED CHILD SUPPORT:

1. Court ordered current child support for child(ren)

not common to the parties $

2. Court ordered cash medical support for child(ren)

not common to the parties $

3. Amount of any arrears payment $

4. Amount per month actually paid in last 12 mos. $

• Attach proof that you are paying

5920

Case No. _________________

5. Name(s) and relationship of minor child(ren) who you support or who live with you, but

are not common to the parties.

G. CO

URT ORDERED SPOUSAL MAINTENANCE/SUPPORT (Alimony):

1. C

ourt ordered spousal maintenance/support you actually

pay to previous spouse: $

H.

EXTRAORDINARY EXPENSES:

1. For Children (Educational Expense/Special Needs/Other): $

Explain:

2. For Self: $

Explain:

7. SCHEDULE OF ALL MONTHLY EXPENSES:

• Do NOT list any expenses for the other party, or children who live with the other party unless

you are paying those expenses.

• Use a monthly average for items that vary from month to month.

• If you are listing anticipated expenses, indicate this by putting an asterisk (*) next to the

estimated amount.

INSTRUCTIONS

Both parties must answer items 7 and 8 if either party is requesting:

• Spousal maintenance

• Division of expenses

• Attorneys’ fees and costs

• Adjustment or deviation from the child support amount

• Enforcement

5920

Case No. _________________

A. HOUSING EXPENSES:

1. House payment:

a. First Mortgage $

b. Second Mortgage $

c. Homeowners Association Fee $

d. Rent $

2. Repair & upkeep $

3. Yard work/Pool/Pest Control $

4. Insurance & taxes not included in house payment $

5. Other (Explain): $

TOTAL: $

B. U

TILITIES:

1. Water, sewer, and garbage $

2. Electricity $

3. Gas $

4. Telephone $

5. Mobile phone/pager $

6. Internet Provider $

7. Cable/Satellite television $

8. Other (Explain): $

TOTAL: $

C.

FOOD:

1. Food, milk, and household supplies $

2. School lunches $

3. Meals outside home $

TOTAL: $

5920

Case No. _________________

D.

CLOTHING:

1. Clothing for you $

2. Uniforms or special work clothes $

3. Clothing for children living with you $

4. Laundry and cleaning $

TOTAL: $

E. T

RANSPORTATION OR AUTOMOBILE EXPENSES:

1. Car insurance $

2. List all cars and individuals covered:

3. Car payment, if any $

4. Car repair and maintenance $

5. Gas and oil $

6. Bus fare/parking fees $

7. Other (explain): $

TOTAL: $

F.

MISCELLANEOUS:

1. School and school supplies $

2. School activities or fees $

3. Extracurricular activities of child(ren) $

4. Church/contributions $

5. Newspapers, magazines and books $

6. Barber and beauty shop $

7. Life insurance (beneficiary: ) $

8. Disability insurance $

5920

Case No. _________________

9. Recreation/entertainment $

10. Child(ren)'s allowance(s) $

11. Union/Professional dues $

12. Voluntary retirement contributions and savings deductions $

13. Family gifts $

14. Pet Expenses $

15. Cigarettes $

16. Alcohol $

17. Other (explain): $

TOTAL: $

8. OUTSTANDING DEBTS AND ACCOUNTS: List all debts and installment payments you currently

owe, but do not include items listed in Item 7 “Monthly Schedule of Expenses”. Follow the

f

ormat below. Use additional paper if necessary.

C

reditor Name Purpose of Debt

Unpaid

Balance

Min.

Monthly

Payment

Date of Your

Last

Payment

Amount of

Your

Payment

5920

Case No. _________________

This page must be completed and attached

to the LAST page of your Document

I filed the ORIGINAL of the attached document(s) with the Clerk of Superior Court in

Maricopa County on:

.

Month Date Year

I mailed/delivered a COPY of the attached document(s) to the Judicial Officer assigned to my case,

Judge (or Commissioner): , on

(Judicial Officer assigned to your case)

Month Date Year

I mailed/delivered a COPY of the attached document(s) to The Office of the Attorney General (The State

of Arizona) on this date (if applicable):

Month Date Year

Address

I mailed/delivered a COPY of the attached document(s) to the Opposing Party and/or his/her Attorney

on:

Month Date Year

Name of Other Side Name of Other Side’s Lawyer

Address Lawyer’s Address

City, State, Zip City, State, Zip

(You must mail a copy of all documents to the other side and his/her lawyer)

By signing below, I state to the Court, under penalty of law, that the information

stated on these pages is true and correct to the best of my knowledge and

belief.

I further state that I have filed/mailed the attached document(s) as shown

above. I understand that if I do not file/mail the attached document(s) as

shown above, the Judge in my case will not read the attached document.

Your signature

5920

Leave the following “Affidavit of

Financial Information” form blank. Serve

the blank form on the other party along

with the other forms you file.

Person Filing:

Address (if not protected):

City, State, Zip Code:

Telephone:

Email Address:

ATLAS Number:

Lawyer’s Bar Number:

Representing Self, without a Lawyer or Attorney for Petitioner OR Respondent

SUPERIOR COURT OF ARIZONA

IN MARICOPA COUNTY

Case No.

Petitioner / Party A ATLAS No.

AFFIDAVIT OF FINANCIAL

INFORMATION

Respondent / Party B Affidavit of

(Name of Person Whose Information is on this

Affidavit)

IMPORTANT INFORMATION ABOUT THIS DOCUMENT

WARNING TO BOTH PARTIES: This Affidavit is an important document. You must fill out this Affidavit

completely, and provide accurate information. You must provide copies of this Affidavit and all other required

documents to the other party and to the judge. If you do not do this, the court may order you to pay a fine.

I have read the following document and know of my own knowledge that the facts and financial information

stated below are true and correct, and that any false information may constitute perjury by me I also

understand that, if I fail to provide the required information or give misinformation, the judge may order

sanctions against me, including assessment of fees for fines under Rule 26, Arizona Rules of Family Law

Procedure.

Date Signature of Person Making Affidavit

FOR CLERK’S USE ONLY

AFI 5920

Case No. _________________

1. GENERAL INFORMATION:

A. Name: Date of Birth:

B. Current Address:

C. Date of Marriage: Date of Divorce:

D. Last date when you and the other party lived together:

E. Full names of child(ren) common to the parties (in this case), their dates of birth:

Name Date of Birth

F. The name, date of birth, relationship to you, and gross monthly income for each individual who

lives in your household:

Name Date of Birth Relationship to you Income

INSTRUCTIONS

1. Complete the entire Affidavit in black ink. If the spaces provided on this form are inadequate,

use separate sheets of paper to complete the answers and attach them to the Affidavit. Answer

every question completely! You must complete every blank. If you do not know the answer to a

question or are guessing, please state that. If a question does not apply, write “NA” for “not

applicable” to indicate you read the question. Round all amounts of money to the nearest dollar.

2. Answer the following statements YES or NO. If you mark NO, explain your answer on a separate piece

of paper and attach the explanation to the Affidavit.

[ ] YES [ ] NO 1. I listed all sources of my income.

[ ] YES [ ] NO 2. I attached copies of my two (2) most recent pay stubs.

[ ] YES [ ] NO 3. I attached copies of my federal income tax return for the last three (3) years,

and I attached my W-2 and 1099 forms from all sources of income.

5920

Case No. _________________

G. Any other person for whom you contribute support:

Name Age Relationship Reside With Court Order to

to You You (Y/N) Support (Y/N)

H. Attorney’s Fees paid in this matter $ . Source of funds

2. EMPLOYMENT INFORMATION:

A. Your job/occupation/profession/title:

Name and address of current employer:

Date employment began:

How often are you paid: [ ] Weekly [ ] Every other week [ ] Monthly [ ] Twice a month

[ ] Other

B. If you are not working, why not?

C. Previous employer name and address:

Previous job/occupation/profession/title:

Date previous job began: Date previous job ended:

Reason you left job:

Gross monthly pay at previous job: $

D. Total gross income from last three (3) years’ tax returns (attach copies of pages 1 and 2 of your

federal income tax returns for the last three (3) years):

Year $ Year $ Year $

E. Your total gross income from January 1 of this year to the date of this Affidavit (year-to-date

income): $

5920

Case No. _________________

3. YOUR EDUCATION/TRAINING: List name of school, length of time there, year of last attendance,

and degree earned:

A. High School:

B. College:

C. Post-Graduate:

D. Occupational Training:

4. YOUR GROSS MONTHLY INCOME:

• List all income you receive from any source, whether private or governmental, taxable or not.

• List all income payable to you individually or payable jointly to you and your spouse.

• Use a monthly average for items that vary from month to month.

• Multiply weekly income and deductions by 4.33. Multiply biweekly income by 2.165 to arrive at

the total amount for the month.

A. Gross salary/wages per month $

• Attach copies of your two most recent pay stubs.

Rate of Pay $ per [ ] hour [ ] week [ ] month [ ] year

B. Expenses paid for by your employer:

1. Automobile $

2. Auto expenses, such as gas, repairs, insurance $

3. Lodging $

4. Other (Explain) $

C. Commissions/Bonuses $

D. Tips $

E. Self-employment Income (See below) $

F. Social Security benefits $

G. Worker's compensation and/or disability income $

H. Unemployment compensation $

I. Gifts/Prizes $

5920

Case No. _________________

J. Payments from prior spouse $

K. Rental income (net after expenses) $

L. Contributions to household living expense by others $

M. Other (Explain:) $

(Include dividends, pensions, interest, trust income, annuities or royalties.)

TOTAL: $

5. SELF-EMPLOYMENT INCOME (if applicable):

If you are self-employed, attach of a copy of the Schedule C for your business from your last tax

return and the most recent income/expense statement from your business.

If self-employed, provide the following information:

Name, address and telephone no. of business:

Type of business entity:

State and Date of incorporation:

Nature of your interest:

Nature of business:

Percent ownership:

Number of shares of stock:

Total issued and outstanding shares:

Gross sales/revenue last 12 months:

INSTRUCTIONS

Both parties must answer item 6 if either party asks for child support. These expenses include only those

expenses for children who are common to the parties, which mean one party is the birth/adoptive mother and

the other is the birth/adoptive father of the children

.

5920

Case No. _________________

6. SCHEDULE OF ALL MONTHLY EXPENSES FOR CHILDREN:

• DO NOT LIST any expenses for the other party, or child(ren) who live(s) with the other party,

unless you are paying those expenses.

• Use a monthly average for items that vary from month to month.

• If you are listing anticipated expenses, indicate this by putting an asterisk (*) next to the

estimated amount.

A. HEALTH INSURANCE:

Do you have health insurance available? Yes No Are you enrolled?_________

1. Total monthly cost $

2. Premium cost to insure you alone $

3. Premium cost to insure child(ren) common to the parties $

4. List all people covered by your insurance coverage:

5. Name of insurance company and Policy/Group Number:

B. DENTAL/VISION INSURANCE:

1. Total monthly cost $

2. Premium cost to insure you alone $

3. Premium cost to insure child(ren) common to the parties $

4. List all people covered by your insurance coverage:

5. Name of insurance company and Policy/Group Number:

5920

Case No. _________________

C. UNREIMBURSED MEDICAL AND DENTAL EXPENSES:

(Cost to you after, or in addition to, any insurance reimbursement)

1. Drugs and medical supplies $

2. Other $

TOTAL: $

D. CHILD CARE COSTS:

1. Total monthly child care costs $

(Do not include amounts paid by D.E.S.)

2. Name(s) of child(ren) cared for and amount per child:

$

3. Name(s) and address(es) of child care provider(s):

E. EMPLOYER PRETAX PROGRAM:

Do you participate in an employer program for pretax payment of child care expenses?

(Cafeteria Plan)? [ ] YES [ ] NO

F. COURT ORDERED CHILD SUPPORT:

1. Court ordered current child support for child(ren)

not common to the parties $

2. Court ordered cash medical support for child(ren)

not common to the parties $

3. Amount of any arrears payment $

4. Amount per month actually paid in last 12 mos. $

• Attach proof that you are paying

5920

Case No. _________________

5. Name(s) and relationship of minor child(ren) who you support or who live with you, but

are not common to the parties.

G. COURT ORDERED SPOUSAL MAINTENANCE/SUPPORT (Alimony):

1. Court ordered spousal maintenance/support you actually

pay to previous spouse: $

H. EXTRAORDINARY EXPENSES:

1. For Children (Educational Expense/Special Needs/Other): $

Explain:

2. For Self: $

Explain:

7. SCHEDULE OF ALL MONTHLY EXPENSES:

• Do NOT list any expenses for the other party, or children who live with the other party unless

you are paying those expenses.

• Use a monthly average for items that vary from month to month.

• If you are listing anticipated expenses, indicate this by putting an asterisk (*) next to the

estimated amount.

INSTRUCTIONS

Both parties must answer items 7 and 8 if either party is requesting:

• Spousal maintenance

• Division of expenses

• Attorneys’ fees and costs

• Adjustment or deviation from the child support amount

• Enforcement

5920

Case No. _________________

A. HOUSING EXPENSES:

1. House payment:

a. First Mortgage $

b. Second Mortgage $

c. Homeowners Association Fee $

d. Rent $

2. Repair & upkeep $

3. Yard work/Pool/Pest Control $

4. Insurance & taxes not included in house payment $

5. Other (Explain): $

TOTAL: $

B. UTILITIES:

1. Water, sewer, and garbage $

2. Electricity $

3. Gas $

4. Telephone $

5. Mobile phone/pager $

6. Internet Provider $

7. Cable/Satellite television $

8. Other (Explain): $

TOTAL: $

C. FOOD:

1. Food, milk, and household supplies $

2. School lunches $

3. Meals outside home $

TOTAL: $

5920

Case No. _________________

D. CLOTHING:

1. Clothing for you $

2. Uniforms or special work clothes $

3. Clothing for children living with you $

4. Laundry and cleaning $

TOTAL: $

E. TRANSPORTATION OR AUTOMOBILE EXPENSES:

1. Car insurance $

2. List all cars and individuals covered:

3. Car payment, if any $

4. Car repair and maintenance $

5. Gas and oil $

6. Bus fare/parking fees $

7. Other (explain): $

TOTAL: $

F. MISCELLANEOUS:

1. School and school supplies $

2. School activities or fees $

3. Extracurricular activities of child(ren) $

4. Church/contributions $

5. Newspapers, magazines and books $

6. Barber and beauty shop $

7. Life insurance (beneficiary: ) $

8. Disability insurance $

5920

Case No. _________________

9. Recreation/entertainment $

10. Child(ren)'s allowance(s) $

11. Union/Professional dues $

12. Voluntary retirement contributions and savings deductions $

13. Family gifts $

14. Pet Expenses $

15. Cigarettes $

16. Alcohol $

17. Other (explain): $

TOTAL: $

8. OUTSTANDING DEBTS AND ACCOUNTS: List all debts and installment payments you currently

owe, but do not include items listed in Item 7 “Monthly Schedule of Expenses”. Follow the

format below. Use additional paper if necessary.

Creditor Name Purpose of Debt

Unpaid

Balance

Min.

Monthly

Payment

Date of Your

Last

Payment

Amount of

Your

Payment

5920

Case No. _________________

This page must be completed and attached

to the LAST page of your Document

I filed the ORIGINAL of the attached document(s) with the Clerk of Superior Court in

Maricopa County on:

.

Month Date Year

I mailed/delivered a COPY of the attached document(s) to the Judicial Officer assigned to my case,

Judge (or Commissioner): , on

(Judicial Officer assigned to your case)

Month Date Year

I mailed/delivered a COPY of the attached document(s) to The Office of the Attorney General (The State

of Arizona) on this date (if applicable):

Month Date Year

Address

I mailed/delivered a COPY of the attached document(s) to the Opposing Party and/or his/her Attorney

on:

Month Date Year

Name of Other Side Name of Other Side’s Lawyer

Address Lawyer’s Address

City, State, Zip City, State, Zip

(You must mail a copy of all documents to the other side and his/her lawyer)

By signing below, I state to the Court, under penalty of law, that the information

stated on these pages is true and correct to the best of my knowledge and

belief.

I further state that I have filed/mailed the attached document(s) as shown

above. I understand that if I do not file/mail the attached document(s) as

shown above, the Judge in my case will not read the attached document.

Your signature

5920

CURRENT EMPLOYER* INFORMATION

You may also fill out this form online at the Family Support Center Website.

THIS FORM MUST BE COMPLETED FOR:

AN INCOME WITHHOLDING ORDER

ORDER TO STOP AN INCOME WITHHOLDING ORDER

NOTIFICATION OF A CHANGE OF EMPLOYER (or OTHER PAYOR)

CASE NUMBER: ATLAS NUMBER:

NAME OF PERSON ORDERED TO MAKE PAYMENTS:

LIST THE NAME OF THE EMPLOYER* AND THE ADDRESS OF THE PAYROLL OR FINANCIAL

DEPARTMENT (for the person named above) WHERE THE INCOME WITHHOLDING ORDER OR

STOP ORDER SHOULD BE MAILED.

EMPLOYER* NAME:

PAYROLL ADDRESS:

CITY: STATE: ZIP:

EMPLOYER* TELEPHONE:

EMPLOYER* FAX:

*or other payor or source of funds

FOR COURT USE ONLY. DO NOT WRITE BELOW THIS LINE.

WA/FSC

For Clerk’s Use Only

WA/LOG ID:

TYPE OF W/A

DATE

AMOUNT OF ORDER

EMPLOYER STATUS

ENTERED BY

NEW W/A

SUB

AG

DCSE

SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY DRS88f-041712

CEI

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