Case Number: _____________
© Superior Court of Arizona in Maricopa County DRS81f-030220
ALL RIGHTS RESERVED
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Payments must include Party A’s or Party B’s name, and Atlas number. Pursuant to
A.R.S. § 25-322, the parties shall submit current address information in writing to the Clerk of
Superior Court and the Support Payment Clearinghouse immediately. The obligor (party being
ordered to pay) shall submit the names and addresses of his or her employers or other payors within
10 days. Both parties shall submit address changes within 10 days of the change.
5. Total Monthly Payments:
Party A Party B shall make total monthly payments to Party A Party B in the
amount of $
________________ per month, payable on the first day of each month, beginning
Current child support payment as ordered above: $
Current spousal maintenance payment: $
Support arrearage payment: $
Clearinghouse handling fee: $ ____________ 8.00
Total monthly payment: $ _________________
6. Medical, Dental, Vision Care Insurance for Minor Children:
Party A OR Party B is responsible for providing medical dental
vision care insurance for the minor child(ren) and shall continue to pay premiums for any medical,
dental and vision policies covering the child(ren) that are currently included in the incorporated
Parent’s Worksheet for Child Support.
Party A OR Party B shall be individually responsible for providing medical
insurance for the minor child(ren) of the parties as soon as it becomes accessible and
available at a r easonable cost, as neither party currently has the ability to obtain such
Medical, dental, and vision insurance, payments and expenses are based on the information in the
Parent’s Worksheet for Child Support attached hereto and incorporated by reference.
The party ordered to pay must keep the other party informed of the insurance company name,
address and telephone number, and must give the other party the documents necessary to submit
insurance claims. An insurance card must be provided to the other party. Notification must also be
provided to the other party if coverage is no longer being provided for the child(ren).
7. Non-Covered Medical Expenses:
Party A is ordered to pay _______ % and Party B is ordered to pay _______ % of all reasonable
uncovered and/or uninsured medical, dental, vision, prescription and other health care charges for
the minor child(ren).
• A request for payment or reimbursement of uninsured medical, dental and/or vision costs must
be provided to the other party within 180 days after the date the services occur.