Revised 12.24.18
DIVORCE
WITH MINOR CHILDREN
For Petitioner Only
(When Parties AGREE to all terms of the Divorce)
PINAL COUNTY
NON-COVENANT MARRIAGE
TO FILE FOR DISSOLUTION (DIVORCE)
OF MARRIAGE WITH CHILDREN
STEP 1
(Please complete step one before proceeding to the next step)
INSTRUCTIONS AND FORMS
Provided as a Public Service by
AMANDA STANFORD
Clerk of the Superior Court
Reset Form
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DIVORCE WITH MINOR CHILDREN
This packet contains general information and instructional forms for filing a divorce petition
for a non- covenant marriage and other court papers when there are minor children. Be sure
this packet contains the following documents:
Order
Title
# of Pages
1
Table of Contents (this page)
1
2
Representing Yourself in Family Court
2
3
Procedures: How to file Divorce Papers with the Court
6
4
Summons
2
5
Notice Regarding Creditors
2
6
Notice of Right to Convert Health Insurance
1
7
Court Order for Parent Education Class & Conciliation Services
2
8
Child Support Calculator for Parents Worksheet
1
9
Parenting Plan
11
10
Affidavit Regarding Minor Children
3
11
Preliminary Injunction
2
12
Sensitive Data Sheet (*NO COPIES REQUIRED)
1
13
Family Court Cover Sheet (*NO COPIES REQUIRED)
2
14
Petition for Dissolution of Non-Covenant Marriage
(Divorce) with Minor Children
16
*NO COPIES REQUIRED. File original only. Do not serve on other party.
You have permission to use these documents 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.
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REPRESENTING YOURSELF IN FAMILY COURT
This brief guide provides some very basic information to help you understand the
proceedings. It does not tell you everything about family law or family court, and it is no
substitute for understanding Title 25 of the Arizona Revised Statutes, the Arizona Rules of
Family Law Procedure, and the Arizona Rules of Evidence. For more information, you should
go to the Pinal County Superior Court website
(www.pinalcountyaz.gov/Departments/JudicialBranch/) or consult a lawyer.
Proceedings in Family Court
Proceedings in Family Court follow the
Arizona Rules of Family Law Procedure
.
In a divorce or paternity case, you may be referred to an Expedited Differentiated Case
Management Conference, Mediation, Family Assessment, or a Settlement Conference
(sometimes called an Alternative Dispute Resolution or “ADR”). These proceedings are
designed to help the parties reach agreement on all or some of their disputes. They generally are
not conducted by your assigned Judge.
You may also have to appear before the Judge for a pretrial hearing. The most common
pretrial hearings are (1) a
Resolution Management Conference
, which helps the Judge
manage the case by, among other things, setting deadlines and a trial date; and (2) a
Temporary
Orders Hearing
, at which the Judge may issue temporary orders to govern the case until the
trial.
If you do not reach a settlement of all issues, there will be a
trial
. This is the single
hearing where the Judge will hear your evidence and make final decisions on disputed issues.
Disclosure and Discovery
To help parties prepare for the trial, the Arizona Rules of Family Law Procedure have
disclosure
and
discovery
requirements.
Disclosure
requirements are in Rule 49. Each party must voluntarily provide certain
information to the other party. You have an obligation to disclose such information to the other
party, and you have a right to insist that the other party disclose such information to you. Failure
to disclose as required may result in sanctions, including being barred from offering evidence
that was not timely disclosed.
If you need information that is not voluntarily disclosed, you may engage in
discovery
,
such as requesting documents from a party or subpoenaing documents from non-parties. Rules
51 through 65 of the Arizona Rules of Family Court discuss the requirements for discovery.
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What is a Trial?
A trial is the time for you and for the other party to present
evidence
on disputed issues.
General Issues If Children Are Involved in Your Case:
Legal decision-making (authority over major matters concerning the children).
Parenting time (what time each parent will spend with the children).
Child support.
Additional Issues If Your Case Involves a Divorce:
Spousal maintenance.
Division of community property and allocation of debts.
The Judge will decide these issues based on the evidence presented during the trial.
Only evidence you bring to the trial will be considered
.
After the trial, the Judge may issue a ruling in open court or may take the case “under
advisement,” which means that the Judge will issue a written ruling at a later time.
The judge’s ruling may be a signed
decree
or
judgment
, which officially concludes the
case. If the judge chooses, the judge may decide disputed issues and then require one or both of
the parties to submit a decree for the judge’s signature.
Preparing for The Trial
When preparing for the trial, it is critical that you read the judge’s minute entries
carefully. The minute entries typically contain the Judge’s requirements for the trial. These
requirements may include:
(1) Submitting a
pretrial statement
that describes the issues in the case and lists your
witnesses and exhibits; and (2) Giving copies of your
exhibits
to the Clerk and to the other
party before the trial.
Many Judges impose
time limits
at the trial. It is your responsibility to make sure you
present all your evidence in the time allotted.
What Happens During the Trial?
The main thing that happens during the trial is the presentation of
evidence
. The Judge
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will make decision based on the evidence presented during the trial. Evidence is generally of two
kinds: (1) Witness testimony and (2) Documents.
When you call a
witness
to testify, you must ask the witness questions. A witness may
only answer questions that are asked. When the party who called a witness is done with
questioning, the other party may “cross-examine” the witness by asking additional questions.
A party may testify as a witness on his or her own behalf. However, while a witness is on
the stand, the parties may only ask questions. Arguing with a witness or commenting on the
answers is not allowed.
Documents
may be evidence at the trial, but you must follow the proper procedure.
Before the trial (usually 5 days before), you must give documents that you want to use to the
Clerk of the Court to be “marked” with an exhibit number. However, marking an exhibit does
not mean it is evidence. Rather, during the trial, you must “offer” the exhibit by asking the judge
to admit it into evidence. The judge then decides whether to admit the evidence. The judge will
consider only evidence that is
admitted
.
Proper Court Behavior
Although family cases are often emotional, it is important that everyone act in an
orderly and respectful way in court. Here are some “Do’s and Don’ts:”
Do dress appropriately. Don’t wear hats, sunglasses, tank tops, shorts, or flip-flops.
Do wait your turn to speak. Don’t interrupt while someone else is talking.
Do treat others with respect. Don’t curse, make faces, or engage in confrontational
behavior.
Do be honest and candid with the judge.
Do make sure that friends and family who accompany you sit quietly. They are not
allowed to speak unless called as a witness, and then only when they are testifying.
For Additional Information
This guide presents very basic information. For additional information, read the
applicable statutes and rules, visit the Pinal County Superior Court website
(www.pinalcountyaz.gov/Departments/Judicial Branch) and if necessary, consult a lawyer.
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PROCEDURES
How to File Papers with the Court for Dissolution of a Non-Covenant Marriage
(Divorce) With Children
(When both Parties Agree)
STEP 1: COMPLETE FORMS
TYPE OR PRINT IN
BLA
C
K INK
PLEASE DO NOT LEAVE ANY QUESTIONS BLANK
Please answer all questions.
If a question does not apply to your case mark “N/A” next to the question. By marking
“N/A” next to the question this informs the Judge or court that a question was “not
applicable” and did not apply to your case or situation.
If there is a question that is not known to you, please indicate “unknown to me”.
STEP 2: SIGN, DATE AND NOTARIZE DOCUMENTS
Documents must be signed and dated in front of ANY Notary Public.
Please look over your documents to ensure all questions have been answered prior to
having your documents notarized.
Please make sure you have a US issued photo ID or driver’s license with you when
having your documents notarized.
STEP 3: MAKE COPIES OF DOCUMENTS
AFTER your documents have been signed, dated and notarized make two (2) copies
of the following documents:
Summons
Notice Regarding Creditors
Notice of Right to Convert Health Insurance
Parents Worksheet for Child Support Amount
Parenting Plan
Order to Attend Parent Education Class
Affidavit Regarding Minor Children
Preliminary Injunction
Petition for Dissolution of Non-Covenant Marriage with Minor Children
Separate your documents into three (3) sets in the following order:
Set 1: ORIGINAL DOCUMENTS
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1. Summons
2. Notice Regarding Creditors
3. Notice of Right to Convert Health Insurance
4. Parents Worksheet for Child Support Amount
5. Parenting Plan
6. Order to Attend Parent Education Class
7. Affidavit Regarding Minor Children
8. Preliminary Injunction
9. Sensitive Data Sheet
10. Family Court Coversheet
11. Petition for Dissolution of Non-Covenant Marriage with Minor Children
Set 2: COPIES FOR YOU THE PETITIONER
1. Summons
2. Notice Regarding Creditors
3. Notice of Right to Convert Health Insurance
4. Parents Worksheet for Child Support Amount
5. Parenting Plan
6. Order to Attend Parent Education Class
7. Affidavit Regarding Minor Children
8. Preliminary Injunction
9. Petition for Dissolution of Non-Covenant Marriage with Minor Children
Set 3: COPIES FOR YOUR SPOUSE THE RESPONDENT
1. Summons
2. Notice Regarding Creditors
3. Notice of Right to Convert Health Insurance
4. Parents Worksheet for Child Support
5. Parenting Plan
6. Order to Attend Parent Education Class
7. Affidavit Regarding Minor Children
8. Preliminary Injunction
9. Petition for Dissolution of Non-Covenant Marriage with Minor Children
STEP 4: FILING FEES
There is a filing fee to file the Petition for Dissolution of Non-Covenant Marriage with Minor
Children and there may be other charges associated with this case. Please check online in our
current Filing Fees section to determine your fee.
DEFERRAL OR WAIVER OF FILING FEES: If you cannot pay these fees, you may
qualify for a deferral or waiver of fees. If you are seeking a deferral or waiver of fees, please
have the Application for Deferral or Waiver of Fees completed and submitted with your
forms.
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ONE of the following is required to be attached to the completed and notarized Application
for Deferral or Waiver of Fees:
A copy of your last two (2) paycheck stubs.
A notarized statement of non-employment. Any persons you are living with at this
time who is assisting you financially may sign a notarized document stating they are
supporting you at this time.
If you receive Food Stamps, SSI, Unemployment or any governmental assistance we
will need a copy or your letter of assignment/award or verification of the amount of
assistance you receive each month.
STEP 5: FILE THE PAPERS WITH THE CLERK OF SUPERIOR COURT
FILING LOCATIONS / FILING IN PERSON / FILING BY MAIL
You may file your documents at any of the Clerk of the Superior Court Locations:
Florence (Main Office) 971 Jason Lopez Circle Bldg. A, Florence, AZ 85132
Open Mon-Fri 8:00 to 5:00
Casa Grande 820 E. Cottonwood Ln Bldg. B, Casa Grande, AZ 85122
Open Mon-Fri 8:00 to 5:00 CLOSING 12:00 to 1:00 for lunch
(Documents requiring a filing fee are not accepted after 4:30)
Apache Junction 575 N. Idaho Rd. Ste. 109, Apache Junction, AZ 85119
Open Mon-Fri 8:00 to 5:00 CLOSING 12:00 to 1:00 for lunch
(Documents requiring a filing fee are not accepted after 4:30)
FILING IN PERSON
To submit the Petition for Dissolution of Non-Covenant Marriage with Minor
Children you should arrive at least two (2) hours before the court closes.
The following must be handed to the Clerk at the Filing Counter:
NOTE: At the time of filing your documents through a deferral, the Clerk can only defer
your filing fees to a later date; THEY ARE NOT WAIVED. Only the Judge can waive your filing fees.
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Original plus two (2) copies of:
Summons
Notice Regarding Creditors
Notice of Right to Convert Health Insurance
Parents Worksheet for Child Support Amount
Parenting Plan
Order to Attend Parent Education Class
Affidavit Regarding Minor Children
Preliminary Injunction
Sensitive Date Sheet (original only)
Family Court Coversheet (original only)
Petition for Dissolution of Non-Covenant Marriage with Minor Children
Required Filing Fee (or) a completed Application for Deferral or Waiver of Filing Fees
with ONE of the following attached to the application:
A copy of your last two (2) paycheck stubs.
A notarized statement of non-employment. Any persons you are living
with at this time who is assisting you financially may sign a notarized
document stating they are supporting you at this time.
If you receive Food Stamps, SSI, Unemployment or any governmental
assistance we will need a copy or your letter of assignment/award or
verification of the amount of assistance you receive each month.
FILING BY MAIL
If you are filing by mail your documents must be mailed to:
Clerk of the Superior Court
P.O. Box 2730
Florence, AZ 85132
To file the Petition for Dissolution of Non-Covenant Marriage with Minor Children by mail,
please mail the following documents:
Original plus two (2) copies of:
Summons
Notice Regarding Creditors
Notice of Right to Convert Health Insurance
Parents Worksheet for Child Support Amount
Parenting Plan
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Order to Attend Parent Education Class
Affidavit Regarding Minor Children
Preliminary Injunction
Sensitive Date Sheet (original only)
Family Court Coversheet (original only)
Petition for Dissolution of Non-Covenant Marriage with Minor Children
Required Filing Fee (or) a completed Application for Deferral or Waiver of Filing Fees
with ONE of the following attached to the application:
A copy of your last two (2) paycheck stubs.
A notarized statement of non-employment. Any persons you are living
with at this time who is assisting you financially may sign a notarized
document stating they are supporting you at this time.
If you receive Food Stamps, SSI, Unemployment or any governmental
assistance we will need a copy or your letter of assignment/award or
verification of the amount of assistance you receive each month.
One appropriate sized self-addressed
stamped
envelope for the return of your
conformed/stamped copies.
STEP 6: SERVING YOUR SPOUSE (THE RESPONDENT)
Although you and your spouse agree to all terms of the divorce, you must still complete
Service upon the other party (the Respondent).
Service means giving legal notice to the other party (the Respondent) that you have
filed court papers and proof of that notice (service) must be filed with the Court.
Service upon the other party (the Respondent) may not be completed until after you
have filed the Court papers with the Court.
There are different ways to serve the other party (the Respondent) you may read
through the different methods of service listed below to help determine which method
of service is right for your case.
Each service method listed below is included in this packet, only ONE method of
service must be completed.
ACCEPTANCE OF SERVICE: the other party must be willing to sign the “Acceptance
of Service” form in front of a Notary Public and return it to you. The other party cannot sign
the Acceptance of Service” until after you have filed the court papers with the court. The
other party’s signature on the “Acceptance of Service” does not mean that he/she agrees with
the court papers. It means that the other party admits receiving the papers, without being
served in person by the sheriff or a process server.
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SERVICE BY CERTIFIED MAIL: This method of service allows you to give notice by a
special type of mail. You can send the court papers by giving the post office copies of the
court papers in an envelope, postage prepaid, to be sent to the other party by any form of mail
requiring a signed and returned receipt. This is often called Certified Mail, Restricted Delivery by
the post office. This means that the other party must sign for the papers. The Post Office
will then return to you a Green Return Receipt containing the other party’s signature. The
Green Return Receipt will then need to be attached to the completed Affidavit of Service by
Certified Mail. The Affidavit of Service by Certified Mail form must be completed/filled out in full
and signed in front of a Notary Public. You will then submit to the Court the original Affidavit
of Service by Certified Mail.
STEP 7: WAITING PERIOD
According to ARS §25-329 the Court shall not consider a submission of a motion supported by affidavit or
hold a trial or hearing on an application for a decree of dissolution of marriage or legal separation until sixty
days after the date of service of process or the date of acceptance of process.
Once you have filed your papers with the Court and served the court documents on the other
party (the Respondent) and filed the appropriate proof of service with the Clerk's office, you
now must wait sixty-one (61) days from the date of service upon the other party (the
Respondent).
If the other party (the Respondent) signed an Acceptance of Service, the sixty-one (61) days
would be counted from the date the Respondent signed before the Notary Public
accepting service of the Court papers.
If the other party (the Respondent) was served by Certified Mail, the sixty-one (61) days
would be counted from the date the Respondent signed the Green Return Receipt.
STEP 8: SUBMITTING YOUR FINAL CONSENT DECREE
If you (the Petitioner) and your spouse (the Respondent) both agree to all terms of the
divorce, you may submit the final Consent Decree. The Consent Decree is the final
document both parties will sign in front of a Notary Public agreeing to all terms of the
divorce. A Consent Decree may be submitted if sixty-one (61) days from the date of
service has passed.
A Consent Decree with children will require additional documents to be attached to
the Consent Decree. Additional orders are also required if spousal support or child
support is being ordered. When submitting a Consent Decree, you are required to
submit the original plus two copies of all documents and orders along with two (2) self-
addressed stamped envelopes.
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The Consent Decree has been included in this packet. The Consent Decree Packet
includes all necessary and/or required forms along with instructions for proper
completion.
The Conciliation Court offers a Family Law Facilitator that is willing to review forms for accuracy
and completeness. There is NO attorney-client relationship established and the Family Law
Facilitator CANNOT provide legal advice. You may however, make an appointment with the
Family Law Facilitator to assist you and your spouse with preparing the final Consent Decree.
They are available to answer general questions, explain court rules, procedures, practices and
review forms.
Call 520-866-5760 or email Mediator-pinal@courts.az.gov for more information.
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Name of Person Filing:
Street Address:
City, State, Zip Code:
Telephone Number:
Email Address:
ATLAS Number (if applicable)
Representing Self (No Attorney)
or Represented by Attorney
If Attorney, Bar Number:
SUPERIOR COURT OF ARIZONA
PINAL COUNTY
CASE NUMBER:
S1100DO2
Name of Petitioner
SUMMONS
Name of Respondent
HONORABLE:
WARNING: This is an official document from the court that affects your rights. Read
this carefully. If you do not understand it, contact a lawyer for help.
FROM THE STATE OF ARIZONA TO
Name of Respondent
1. A lawsuit has been filed against you. A copy of the lawsuit and other court papers are served
on you with this
“Summons.”
2. If you do not want a judgment or order taken against you without your input, you must file
an
“Answer”
or a
“Response
in writing with the court, and pay the filing fee. If you do not
file an
“Answer”
or
“Response
the other party may be given the relief requested in his/her
Petition or Complaint. To file your
“Answer”
or
“Response”
take, or send, the
“Answer”
or
“Response”
to the Office of the Clerk of the Superior Court, 971 Jason Lopez Circle Bldg
A , Florence, Arizona 85132 or PO Box 2730, Florence, Arizona 85132-2730; or any satellite
office. Mail a copy of your
“Response”
or
“Answer”
to the other party at the address listed
on the top of this Summons.
3. If this
“Summons”
and the other court papers were served on you by a registered process
server or the Sheriff, within the State of Arizona, your
“Response”
or
“Answer”
must be
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filed within TWENTY (20) CALENDAR DAYS from the date you were served, not
counting the day you were served. If this
“Summons”
and the other papers were served
on you by a registered process server or the Sheriff outside the State of Arizona, your
Response must be filed within THIRTY (30) CALENDAR DAYS from the date you were
served, not counting the day you were served. Service by a registered process server or the
Sheriff is complete when made. Service by Publication is complete thirty (30) days after the
date of the first publication.
4. You can get a copy of the court papers filed in this case from the Petitioner at the address at
the top of this paper, or from the Clerk of the Superior Court at the address listed in Paragraph
2 above.
5. If this is an action for dissolution (divorce), legal separation or annulment, either or both
spouses may file a Petition for Conciliation for the purpose of determining whether there is
any mutual interest in preserving the marriage or for Mediation to attempt to settle disputes
concerning Legal Decision-Making and parenting time issues regarding minor children.
6. Requests for reasonable accommodation for persons with disabilities must be made to the
office of the judge or commissioner assigned to the case, at least five (5) days before your
scheduled court date.
GIVEN UNDER MY HAND AND SEAL OF THE COURT
Date
Amanda Stanford
Clerk of the Superior Court
By
Deputy Clerk
Case Number: S1100DO2
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Name of Person Filing:
Street Address:
City, State, Zip Code:
Telephone Number:
Email Address:
ATLAS Number (if applicable)
Representing Self (No Attorney)
or Represented by Attorney
If Attorney, Bar Number:
SUPERIOR COURT OF ARIZONA
PINAL COUNTY
CASE NUMBER:
S1100DO2
Name of Petitioner
NOTICE REGARDING CREDITORS
Name of Respondent
HONORABLE:
ARIZONA LAW REQUIRES all actions for DIVORCE or LEGAL SEPARATION to
include this NOTICE and for the person filing for Divorce or Legal Separation to SERVE
this NOTICE on the other party. (ARS 25-318(F).
YOU AND YOUR SPOUSE ARE RESPONSIBLE FOR COMMUNITY DEBTS. The court
usually requires/orders one spouse or the other to pay certain community debts in, or through, the
Decree of Dissolution or Legal Separation. A court order that does this is binding on the spouses
only, not the creditors. You and your spouse are legally responsible for these community debts
whether you are married, divorced, or legally separated. These debts are matters of contract between
both of you and your creditors (such as banks, credit unions, credit card companies, utility companies,
medical providers and retailers). On request, the court may impose a lien against the separate property
of a spouse to secure payment of certain community debts.
CONTACT CREDITORS: You may want to contact your creditors to discuss the debts and the
effects of your divorce/legal separation on your debts. To assist you in identifying your creditors, you
may obtain a copy of your spouse's credit report by making a written request to the court for an order
requiring a credit reporting agency to release the report to you. The credit report will help you identify
accounts, account numbers and account balances. In addition, within thirty (30) days after receipt of
a request from a spouse who is party to a divorce or legal separation, which includes the court and
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cause number of the action, creditors are required, by law, to provide information as to the balance
and account status of any debts for which you or your spouse may be liable to the creditor.
WARNING: If you do not understand this notice, you should contact an attorney for advice
about your legal rights and obligations.
The following page contains a sample form you
may
choose to mail to creditors to get
information about debts owed by you or your spouse. It is not a required form.
Case Number: S1100DO2
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REQUEST FOR ACCOUNT INFORMATION FROM CREDITORS
You may use this form to request information about debt owed by you or your spouse.
If so, send to the creditor. DO NOT FILE THIS PAGE WITH THE COURT.
DATE:
CREDITOR’S NAME:
CREDITOR’S ADDRESS:
Regarding:
Superior Court of Arizona in Pinal County
Case Name:
Case Number:
S1100
Pursuant to Arizona State Law (ARS 25-318), this letter requests the balance and account status of
any debt for which the following individuals may be liable to you. (Arizona law requires that you
provide this information within thirty (30) days of receipt of this letter.)
INFORMATION ABOUT DEBTORS/SPOUSES:
Your Name:
Your Address:
Your Phone Number:
Your Spouse’s Name:
Your Spouse’s Address:
INFORMATION ABOUT THE ACCOUNT:
Account Number(s):
If you have any questions or if I can be of further assistance, please feel free to contact me.
Sincerely,
Your Name:
Your Signature:
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SUPERIOR COURT OF ARIZONA
PINAL COUNTY
CASE NUMBER:
S1100DO2
Name of Petitioner
NOTICE OF YOUR RIGHTS ABOUT
HEALTH INSURANCE COVERAGE
WHEN A PETITION FOR
DISSOLUTION (DIVORCE) IS FILED
(A.R.S. 20-1377 AND 20-1408)
Name of Respondent
HONORABLE:
WARNING: THIS IS AN IMPORTANT LEGAL NOTICE. YOUR RIGHTS TO
HEALTH INSURANCE COVERAGE COULD BE AFFECTED AFTER YOUR
DIVORCE IS FINAL. READ THIS NOTICE CAREFULLY. IF YOU DO NOT
UNDERSTAND THIS NOTICE, YOU SHOULD CALL AN ATTORNEY FOR
ADVICE ABOUT YOUR LEGAL RIGHTS AND OBLIGATIONS.
IMPORTANT INFORMATION IF YOU ARE ON YOUR SPOUSE'S INSURANCE
PLAN: When a Petition for Dissolution of Marriage (papers for a divorce decree) is filed, you and/or
your children may continue to be covered under your spouse's health insurance policy. Arizona law
allows the dependent spouse and/or children to continue to be covered, but you must take some
steps to protect your rights.
WHAT INSURANCE COVERAGE APPLIES TO YOU, AND HOW TO GET IT: If you are
covered by your spouse's health insurance, and you want to continue to be covered after the divorce
is final, you must contact the insurance company as soon as possible, and you must start to pay the
monthly insurance premium within 31 days of the date the insurance would otherwise stop.
If you decide you want to be covered, the insurer can choose whether to continue coverage under
the current policy, or to change the policy to your name. If the policy is changed to your name, it is
called a "converted"; policy. If the policy is converted by the insurer, the insurer must provide you
the same or the most similar level of coverage available, unless you ask for a lower level of coverage.
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WHAT COVERAGE APPLIES TO YOUR CHILDREN: If you choose to continue coverage
as a dependent spouse, you can also choose to continue coverage for your dependent children if you
are responsible for their care or support.
PREEXISTING CONDITIONS OR EXCLUSIONS FROM INSURANCE COVERAGE:
Whether the insurance is continued or converted, the insurance must be provided to you without
proof of insurability and without exclusions for coverage other than what was previously excluded
before the insurance was continued or converted.
LIMITS ON RIGHTS TO INSURANCE COVERAGE FOR YOU AND YOUR
CHILDREN: You may not be entitled to continued or converted coverage if you are eligible for
Medicare or for coverage by other similar types of insurance which together with the continued
coverage would make you over-insured. However, dependent children of a person who is eligible for
Medicare may be covered by a continuance or a conversion. If you have questions about coverage,
check with the insurer and/or the spouse's employer.
WARNING TO THE SPOUSE FILING THE PETITION FOR DISSOLUTION
(DIVORCE): This Notice must be served on your spouse together with the Petition for
Dissolution, the Summons, and the Preliminary Injunction.
Case Number: S1100DO2
ARIZONA SUPERIOR COURT, PINAL COUNTY
ORDER TO PARENT EDUCATION CLASS
THIS IS AN OFFICIAL ORDER. IF YOU DISOBEY THIS ORDER, THE COURT MAY FIND
YOU IN CONTEMPT.
Pursuant to A.R.S. '25-352, IT IS ORDERED you must attend and complete a parent education course
within the following time limits:
1.
Petitioner: You must complete the course within 45 days from the filing of the petition.
2.
Respondent
:
You must complete the course within 45 days of being served with or accepting service
of the petition. The Respondent must complete the course whether or not a response to the action is
filed.
3.
Paternity Proceeding: If paternity has been established, you must complete the class as described
above. If paternity has not been established, you are welcome to complete the class at your earliest
convenience. However, you are not required to complete the class until paternity has been
established by the court.
4. Compliance: A.R.S. '25-353. Failure to comply - if a party fails to complete the educational program
as ordered pursuant to section 25-352, the court may deny relief in favor of that party, hold that
party in contempt of court or impose any other sanction reasonable under the circumstances. The
court will be notified if you fail to complete the class.
Exceptions: If you have completed the class
within less than 1 year or the court excuses a party’s participation.
5.
Class Fee: Each party shall pay the $40.00 fee to, or obtain a valid fee deferral from, the Clerk of
the Superior Court (see attached Notice for fee payment instructions).
6.
Disability: If, due to a disability, you need special accommodations for your attendance such as
auxiliary aids, or materials in alternative formats, please contact Family Services of the Conciliation
Court as soon as you receive this notice.
7.
Information: Additional information about Parent Education is available at
www.pinalcountyaz.gov/Judicial/ConciliationCourt.
8.
Registration: You may register for the course online at
www.pinalcountyaz.gov/Judicial/ConciliationCourt/Pages/ParentEducationClass.aspx, or by
phone at 520-866-5760.
Joseph R. Georgini
Honorable Joseph R. Georgini, Date
Presiding Judge, Family Court
CASE NUMBER S1100DO2
You have been ordered to attend a Parent Education Class. The Parent Education Class is taught by
counselors from Family Services of Conciliation Court. You are required to complete the entire class to
receive a copy of the
Notice of Completion and Certificate
that will be filed with the court. If you fail to comply,
the Court may deny relief, hold you in contempt of court, or impose any other sanction reasonable under the
circumstances. (A.R.S. 25-352)
The court will be notified if you fail to attend the class.
THIS IS A 3 STEP PROCESS.
1.
PAY FOR THE CLASS WITH CLERK OF SUPERIOR COURT
2.
REGISTER FOR THE CLASS WITH FAMILY SERVICES OF CONCILIATION COURT
3.
ATTEND the 4 HOUR CLASS IN FLORENCE WITH PROOF OF PAYMENT
1.
Use one of the following methods to pay for the Class: The cost is $40.00 per person.
ONLINE: Make payment to via website:
https://client.pointandpay.net/recurring/PinalCountySuperiorCourtAZ
PHONE: Call 800.487.4567.
MAIL: Mail personal checks, cashiers check or money order for $40.00 payable to Clerk of the
Superior Court at the following address:
Clerk of the Superior Court Parent Education Course
P.O. Box 2730
Florence, AZ 85132-2730
Write your court case number and
Parent Education Class”
on the cashiers check, money order or
personal check. IMPORTANT: You MUST enclose a self-addressed stamped envelope so the clerk’s office will
mail your receipt to you.
IN PERSON: Payments can be made by cash, money order, MasterCard, Visa, Discover and American
Express with valid ID of card holder at any of our office locations listed below.
Florence 971 N Jason Lopez Cir., Bldg. A
Apache Junction 575 N Idaho, Ste. 109
Casa Grande 820 E. Cottonwood Ln., #B
For more information about obtaining a fee deferral, contact any clerk’s office
Contact Information for all Offices
Toll Free: 888.431.1311 • Local: 520.509.3555 or 311 • Fax: 520.866.5320
www.coscpinalcountyaz.gov/office.html
2.
Register for the Class with Family Services of Conciliation Court: Sign up online at
www.pinalcountyaz.gov/Judicial/ConciliationCourt or by phone at 520-866-5760.
3.
Attend the Class: Bring photo I.D. and proof of payment or fee deferral to the class. Please arrive 15 minutes
early.
Justice Complex (Highway 79)
Pinal County Superior Courthouse
971 Jason Lopez Cir., Bldg. A Florence, AZ 85132
*No children are allowed in class
*
If you reside outside of Pinal County, you are still required to complete a parent education class (A.R.S. 25-
352). Please visit the website for information:
http://www.pinalcountyaz.gov/Judicial/ConciliationCourt/Pages/DVDRequestForm.aspx
PARENT EDUCATION CLASS NOTICE
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CHILD SUPPORT CALCULATOR for
Parent’s Worksheet to determine Child Support Amount
The Court Self Help website offers a Free Child Support Calculator
and Fillable Forms.
Simple
Quick
Accurate
If you have a personal computer with Internet access,
you can access the Child Support Calculator at:
http://www.azcourts.gov/familylaw
You may also visit the Law Library at the
Pinal County Superior Court House for access and further assistance.
Your computer must be connected to a printer. Begin by selecting which Child Support Calculator applies to you,
2005 or 2011, and then press the Tab button on your keyboard to move through the form, or click on each field with
your mouse.
Enter the appropriate information in each blank field. Not every blank field needs to be completed in every case. If
you are not sure whether you should complete a blank field, click on the question mark (?) next to the blank field.
You will receive additional information in accordance with the Arizona Child Support Guidelines.
When you have completed the Entry Form, click the "Print Worksheet" button to receive an estimate of the amount
of child support the non- custodial parent may have to pay to the custodial parent for the support of their child(ren).
After clicking on "Print Worksheet" the form will automatically be filled in with the information from the Entry Form.
Print the form and bring it with you at the time of filing your initial paperwork.
The Court Self Help website also offers the following fillable forms required to set up Child Support, select the
“Forms” tab to make your selection:
Child Support Order
Post Paternity Establishment of Child Support Order
Paternity Judgment Child Support Order
To have the Child Support amount automatically deducted from payroll, either of the below forms must be
submitted:
Income Withholding Order May be completed by either party
Current Employer Information To be completed by the non-custodial parent/obligor/payer only
Calculate Support for Parent’s Worksheet
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Name of Person Filing:
Street Address:
City, State, Zip Code:
Telephone Number:
Email Address:
ATLAS Number (if applicable):
Representing Self (No Attorney) or Represented by Attorney
If Attorney, Bar Number:
SUPERIOR COURT OF ARIZONA
PINAL COUNTY
CASE NUMBER:
S1100DO2
Name of Petitioner
PARENTING PLAN FOR:
JOINT LEGAL DECISION-MAKING
OR
SOLE LEGAL DECISION-MAKING
TO PETITIONER
TO RESPONDENT
Name of Respondent
HONORABLE:
GENERAL INFORMATION
A. MINOR CHILDREN This Plan concerns the following children common to the parents:
Name Birth Date
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B. LEGAL DECISION-MAKING:
Select One.
SOLE LEGAL DECISION-MAKING
Sole legal decision-making should be granted to
Petitioner or
Respondent
JOINT LEGAL DECISION-MAKING
EDUCATIONAL DECISIONS: Each parent has the right to participate in school
conferences, events and activities, and the right to consult with teachers and other
school personnel. (Select one)
Petitioner Respondent will make final Education Decisions
appropriate under all circumstances after good faith consultations with the
other parent.
Both parents shall make Education Decisions together
The children will not be moved to a school located outside of the school
district where they are currently enrolled without written agreement by both
parties.
Both parents will sign this Parenting Plan and agree that the children will
attend the following private school:
Other (specify):
RELIGIOUS DECISIONS (Select one)
Petitioner Respondent will make final Religious Decisions
appropriate under all circumstances after good faith consultations with the
other parent.
Both parents shall make Religious Decisions together
Petitioner shall make Religious Decisions
Respondent shall make Religious Decisions
MEDICAL DECISIONS (Select one)
Petitioner Respondent will make final Medical Decisions
appropriate under all circumstances after good faith consultations with the
other parent.
Both parents shall make Medical Decisions together
Case Number: S1100DO2
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Petitioner shall make Medical Decisions
Respondent shall make Medical Decisions
PERSONAL CARE DECISIONS (Select one)
Petitioner Respondent will make final Personal Decisions
appropriate under all circumstances after good faith consultations with the
other parent.
Both parents shall make Personal Care Decisions together
Petitioner shall make Personal Care Decisions
Respondent shall make Personal Care Decisions
C. PARENTING TIME Write your detailed parenting plan below. Include specific times,
locations, and details regarding transportation. You will have the opportunity to request
supervised parenting time or no parenting time, later in this document.
1. Regular Parenting Time:
2. Summer Months:
Case Number: S1100DO2
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3. School Breaks Longer Than 4 Days:
4. Three Day Weekends:(for example, Labor Day, Columbus Day, Martin Luther King, Jr.
Day, Presidents' Day and Memorial Day)
The parents agree that whichever of them has the child(ren) for the weekend occurring
nearer in time to the holiday will spend time with the child(ren) for the holiday, OR
Explain your request:
5. Transportation: Write your procedure for exchanges of the child(ren) including location
and responsibility for transportation.
6. Holiday, Birthday and Special Occasion Schedule Use the table below or the blank
space to write your schedule.
Event Even Years Odd Years
New Year’s Eve Petitioner Respondent Petitioner Respondent
New Year’s Day Petitioner Respondent Petitioner Respondent
Easter Petitioner Respondent Petitioner Respondent
4
th
of July Petitioner Respondent Petitioner Respondent
Halloween Petitioner Respondent Petitioner Respondent
Veteran’s Day Petitioner Respondent Petitioner Respondent
Case Number: S1100DO2
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Thanksgiving Petitioner Respondent Petitioner Respondent
Christmas Eve Petitioner Respondent Petitioner Respondent
Christmas Day Petitioner Respondent Petitioner Respondent
Child(ren)’s Birthday Petitioner Respondent Petitioner Respondent
Mother’s Day Petitioner Respondent Petitioner Respondent
Father’s Day Petitioner Respondent Petitioner Respondent
Petitioner’s Birthday Petitioner Respondent Petitioner Respondent
Respondent’s Birthday Petitioner Respondent Petitioner Respondent
7. Telephone Contact with Children
Each parent may have telephone contact with the child(ren) during the child(ren)’s normal
waking hours, OR
Explain your request:
8. Travel with Child(ren) (all of the following are optional)
Each parent is entitled to consecutive days of vacation time per year with the
child(ren). Each parent will give the other parent days notice prior to the vacation.
Should either parent travel out of the area with the minor child(ren), each parent will keep
the other parent informed of travel plans, address(es), and telephone numbers at which that
parent and the minor child(ren) can be reached.
Neither parent shall travel with the minor child(ren) outside of Arizona for longer than
______ days without the prior written consent of the other parent or order of the court.
SUPERVISED PARENTING TIME
Supervised parenting time is in the best interest of the minor child(ren) because:
Case Number: S1100DO2
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Name of the agency or person who will supervise:
NO PARENTING TIME BETWEEN CHILD(REN) AND
PETITIONER
OR
RESPONDENT
No parenting time is in the best interest of the minor child(ren) because:
D. Medical and Dental Arrangements
Both parents have the right to authorize emergency medical treatment, if needed, and the
right to consult with physicians and other medical practitioners. Both parents agree to advise
the other parent with physicians and other medical practitioners. Both parents agree to advise
the other parent immediately of any emergency medical/dental care sought for the minor
children, to cooperate on health matters concerning the children and to keep one another
reasonably informed. Both parents agree to keep each other informed as to names, addresses
and telephone numbers of all medical/dental care providers.
E. Other Arrangements
Each parent will inform the other parent of any change of address and/or phone number
in advance OR within days of the change.
Both parents will promptly inform the other parent of any emergency or other important
event that involves the minor children.
Both parents will consult and agree with the other parent regarding any extra activity that
affects the minor children’s access to the other parent.
Case Number: S1100DO2
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Each parent will consider the other parent as care-provider for the minor children before
making other arrangements.
Each parent will keep all communication regarding the minor child(ren) between the
parents and will not use the minor child(ren) to convey information or to set up parenting
time changes.
Each parent will encourage love and respect between the minor child(ren) and the other
parent and neither parent shall do anything that may hurt the other parent’s relationship with
the minor children.
Both parents will exert their best efforts to work cooperatively in future plans consistent
with the best interests of the minor children and to amicably resolve such disputes as may
arise.
If either parent is unable to follow through with the time-sharing arrangements involving
the minor child(ren), that parent will notify the other parent as soon as possible.
Both parents agree that if either parent moves out of the area and returns later, they will
use the most recent “Parenting Plan/Access Agreement” in place before the move.
If the parents are unable to reach a mutual agreement regarding a legal change to their
parenting orders, they will request mediation through the court or a private mediator of their
choice.
Obtain Written Consent or Court Order Before Moving: Notice required by ARS 25-408
shall be made by certified mail, return receipt requested, or pursuant to the Arizona rules of
family law procedure. The court shall sanction a parent who, without good cause, does not
comply with the notification requirements of this law. The court may impose a sanction that
will affect the legal decision-making or parenting time only in accordance with the child’s best
interests.
Parental Access to Records and Information Pursuant to Arizona law, unless otherwise
provided by court order or law, on reasonable request both parents are entitled to have equal
access to documents and other information concerning the minor child(ren)’s education and
physical, mental, moral and emotional health including medical, school, police, court and other
records. A person who does not comply with a reasonable request for these records shall
reimburse the requesting parent for court costs and attorney fees incurred by that parent to
make the other parent obey this request. A parent who attempts to restrict the release of
documents or information by the custodian of the records without prior court order is subject
to legal sanctions.
Case Number: S1100DO2
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Notice: Do not deviate from Parenting Plan until dispute is resolved. Both parents are
advised that while a dispute is being resolved, neither parent shall deviate from this Parenting
Plan or act in a way that is inconsistent with the terms of this agreement.
Once this plan has been made an order of the Court, if either parent disobeys the court order
related to parenting time with the children, the other parent may submit court papers to
request enforcement.
SIGNATURE OF ONE OR BOTH PARENTS
Signature of Petitioner: Date:
Signature of Respondent: Date:
Case Number: S1100DO2
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IF YOU ARE REQUESTING SOLE LEGAL DECISION MAKING, THE FORM IS
COMPLETE. DO NOT SIGN SECTION F OR G.
F. STATEMENT REGARDING CONTACT WITH SEX OFFENDERS AND
PERSONS CONVICTED OF DANGEROUS CRIMES AGAINST CHILDREN.
According to A.R.S. §25-403.05, a child’s parent or custodian must immediately notify the other
parent or custodian if the person knows that a convicted or registered sex offender or someone who
has been convicted of a dangerous crime against children may have access to the child.
According to A.R.S. §13-705 (P) (1), “Dangerous crime against children” means any of the following
that is committed against a minor who is under fifteen years of age:
(a) Second degree murder.
(b) Aggravated assault resulting in serious physical injury or involving the discharge, use or
threatening exhibit on of a deadly weapon or dangerous instrument.
(c) Sexual assault.
(d) Molestation of a child.
(e) Sexual conduct with a minor.
(f) Commercial sexual exploitation of a minor.
(g) Sexual exploitation of a minor.
(h) Child abuse as prescribed in section 13-3623, subsection A, paragraph 1.
(i) Kidnapping.
(j) Sexual abuse.
(k) Taking a child for the purpose of prostitution as prescribed in section 13-3212.
(l) Child prostitution as prescribed in section 13-3212.
(m) Involving or using minors in drug offenses.
(n) Continuous sexual abuse of a child.
(o) Attempted first-degree murder.
(p) Sex trafficking.
(q) Manufacturing methamphetamine under circumstances that causes physical injury to a minor.
(r) Bestiality as prescribed in section 13-1411, subsection A, paragraph 2.
(s) Luring a minor for sexual exploitation.
(t) Aggravated luring a minor for sexual exploitation.
(u) Unlawful age misrepresentation.
Case Number: S1100DO2
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The parent or custodian must provide notice by first class mail, return receipt requested, by electronic
means to an electronic mail address that the recipient provided to the parent or custodian for
notification purposes or by another form of communication accepted by the court.
I/We have read, understand, and agree to abide by the requirements of A.R.S. §25-403.05(B)
concerning notification of other parent or custodian if someone convicted of dangerous crime against
children may have access to the child.
Signature of Petitioner: Date:
Signature of Respondent: Date:
G. JOINT LEGAL DECISION-MAKING: If requested or agreed to by the parties, the
following will apply, subject to approval by the Judge:
1. DOMESTIC VIOLENCE: Arizona Law (A.R.S. §25-403.03) states that joint Legal
Decision-Making shall NOT be awarded if there has been “a history of significant domestic
violence”.
Domestic Violence has not occurred between the parties, OR
Domestic Violence has occurred but it has not been “significant” or has been committed
by both parties.* Complete Section 3 below.
2. DUI or DRUG CONVICTIONS:
Neither party has been convicted of driving under the influence or a drug offense within
the past 12 months, OR
One of the parties HAS been convicted of driving under the influence or a drug offense
within the past 12 months, but the parties feel Joint Legal Decision-Making is in the best
interest of the children. * Complete Section 3 below.
3. * IF THERE HAS BEEN DOMESTIC VIOLENCE OR A DUI OR DRUG
CONVICTION:
Explain why Joint Legal Decision-Making is still in the best interests of the children:
Case Number: S1100DO2
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4. REVIEW: The parents agree to review the terms of the / this agreement and make any
necessary or desired changes every months from the date of this document.
5. CRITERIA. Our joint Legal Decision-Making agreement meets the criteria required by
Arizona law A.R.S. §25-403.02, as listed below:
a. The best interest of the minor children are served;
b. Each parent’s rights and responsibilities for personal care of the minor children and
for decisions in education, health care and religious training are designated in this Plan;
c. A schedule of the physical residence of the minor children, including holidays and
school vacations is included in the Plan;
d. The Plan includes a procedure for periodic review;
e. The Plan includes a procedure by which proposed changes, disputes and alleged
breaches may be mediated or resolved;
f. A procedure for communicating with each other about the child, including methods
and frequency.
SIGNATURE OF PARENT(S) REQUESTING JOINT LEGAL DECISION-MAKING
Signature of Petitioner: Date:
Signature of Respondent: Date:
Case Number: S1100DO2
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Name of Person Filing:
Street Address:
City, State, Zip Code:
Telephone Number:
Email Address:
ATLAS Number (if applicable)
Representing Self (No Attorney)
or Represented by Attorney
If Attorney, Bar Number:
SUPERIOR COURT OF ARIZONA
PINAL COUNTY
CASE NUMBER:
S1100DO2
Name of Petitioner
AFFIDAVIT REGARDING
MINOR CHILDREN
Name of Respondent
HONORABLE:
NOTICE: This
“Affidavit Regarding Minor Children”
is required for all legal decision-
making cases. You must fill out this Affidavit completely, and provide accurate information.
Use additional paper if necessary. You must give copies of this Affidavit and all other
required documents to the other party, and to the judge.
1. CHILDREN OF THE PARTIES WHO ARE UNDER 18 YEARS OLD. The
following child(ren) are under age 18 and were born to, or adopted by, me and the other
party:
Name:
Name:
Birth Date:
Age:
Birth Date:
Age:
Name:
Name:
Birth Date:
Age:
Birth Date:
Age:
2. INFORMATION REGARDING WHERE THE CHILDREN UNDER 18 YEARS
OLD HAVE LIVED FOR THE LAST 5 YEARS: (Attach additional pages if necessary)
Child’s Name:
Dates: From
To
Address:
Lived with:
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City, State:
Relationship to Child:
Child’s Name:
Dates: From
To
Address:
Lived with:
City, State:
Relationship to Child:
Child’s Name:
Dates: From
To
Address:
Lived with:
City, State:
Relationship to Child:
3. COURT CASES IN WHICH I HAVE BEEN A PARTY/WITNESS THAT
INVOLVED THE LEGAL DECISION-MAKING PARENTING TIME OF THE
CHILD(REN): (Check one box)
I have or I have not been a party/witness in court in this state or in any other state that
involved the legal decision-making parenting time of the child(ren) named above. (If so,
explain on separate paper. If not, go on.)
Name of each child:
Name of Court:
Court Location:
Court Case Number:
Current Status:
How the child is involved:
Summary of any Court Order:
4. INFORMATION REGARDING PENDING COURT CASES RELATED TO THE
LEGAL DECISION-MAKING OF THE CHILD(REN): (Check one box)
I do have or I do not have information about a legal decision-making parenting time
court case relating to any of the children named above that is pending in this state or in any
other state. (If so, explain. If not, go on.)
Name of each child:
Name of Court:
Court Location:
Court Case Number:
Current Status:
How the child is involved:
Summary of any Court Order:
5. LEGAL DECISION-MAKING OR PARENTING TIME CLAIMS OF ANY
PERSON: (Check one box)
I do know or I do not know a person other than the Petitioner or the Respondent who
has physical legal decision-making or who claims legal decision-making or parenting time
rights to any of the children named in this Affidavit.
(If so, explain below. If not, go on.)
Case Number: S1100DO2
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Name of each child:
Name of person with the claim:
Address of person with the claim:
Nature of the claim:
OATH OR AFFIRMATION AND VERIFICATION:
I swear or affirm that the information on this document is true and correct under penalty of
perjury.
Date
Signature
State of Arizona )
)
County of )
Subscribed and sworn (or affirmed) before me this
day of
,
20
(Day)
(Month)
(Year)
by
(Name of Signer)
(Affix notary seal here)
Notary Public (Notary’s Signature)
Case Number: S1100DO2
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Name of Person Filing:
Street Address:
City, State, Zip Code:
Telephone Number:
Email Address:
ATLAS Number (if applicable)
Representing Self (No Attorney)
or Represented by Attorney
If Attorney, Bar Number:
SUPERIOR COURT OF ARIZONA
PINAL COUNTY
CASE NUMBER:
S1100DO2
Name of Petitioner
PRELIMINARY INJUNCTION
Name of Respondent
HONORABLE:
WARNING: This is an official Order from the court. It affects your rights. Read this
Order immediately and carefully. If you do not understand it, contact a lawyer for help.
Your spouse has filed a
“Petition for Dissolution”
(Divorce) or
“Petition for Annulment”
or
“Petition for Legal
Separation”
with the court. This Order is made at the direction of the Presiding
Judge of the Superior Court of Arizona in Pinal County. This Order has the same force and effect
as any order signed by the judge. You and your spouse must obey this Order. This Order may be
enforced by any remedy available under the law, including an
“Order of
Contempt of Court.”
To
help you understand this Order, we have provided this explanation. Read the explanation and then
read the statute itself. If you have any questions, you should contact a lawyer for help.
EXPLANATION: (What does this Order mean to you?)
1. ACTIONS FORBIDDEN BY THIS ORDER: From the time the
“Petition for
Dissolution”
(Divorce) or
“Petition for Annulment”
or
“Petition for Legal Separation”
is filed with the court, until the judge signs the Decree, or until further order of the court, both
the Petitioner and the Respondent shall not do any of the following things:
You may not hide earnings or community property from your spouse, AND
You may not take out a loan on the community property, AND
You may not sell the community property or give it away to someone, UNLESS you have
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the written permission of your spouse or written permission from the court. The law allows
for situations in which you may need to transfer joint or community property as part of the
everyday running of a business, or if the sale of community property is necessary to meet
necessities of life, such as food, shelter, or clothing, or court fees and attorney fees associated
with this action. If this applies to you, you should see a lawyer for help, AND
Do not harass or bother your spouse or the children, AND
Do not physically abuse or threaten your spouse or the children, AND
Do not take the minor children, common to your marriage, out of the State of Arizona for
any reasons, without a written agreement between you and your spouse or a Court Order,
before you take the minor children out of the State.
Do not remove, or cause to be removed, the other party or the minor children of the parties from
any existing insurance coverage, including medical, hospital, dental, automobile and disability
insurance. Both parties shall maintain all insurance coverage in full force and effect.
STATUTORY REQUIREMENTS: Arizona Law, A.R.S. 25-315(A) provides:
1(a). RESTRICTIONS ON PROPERTY OF THE MARRIAGE: That both parties are
enjoined from transferring, encumbering, concealing, selling, or otherwise disposing of any of
the joint, common or community property of the parties, except if related to the usual course
of business, the necessities of life, or court fees and reasonable attorney fees associated with
an action filed under this article, without the written consent of the parties or the permission
of the court.
1(b). REQUIREMENTS OF BEHAVIOR: That both parties are enjoined from molesting,
harassing, disturbing the peace, or committing an assault or battery on, the person of the other
party or any natural or adopted child of the parties.
1(c). RESTRICTIONS ABOUT YOUR MINOR CHILDREN: That both parties are enjoined
from removing any natural or adopted minor child(ren) of the parties, then residing in Arizona,
from the jurisdiction of the court without the prior written consent of the parties or the
permission of the court.
1(d). RESTRICTIONS ABOUT INSURANCE: That both parties are enjoined from removing,
or causing to be removed, the other party or the minor children of the parties from any existing
insurance coverage, including medical, hospital, dental, automobile and disability insurance.
Both parties shall maintain all insurance coverage in full force and effect.
2. EFFECTIVE DATE OF THIS ORDER: This Order is effective against the person who
filed for divorce, annulment, or legal separation (the Petitioner) when the Petition was filed
with the court. It is effective against the other party (the Respondent) when it is served on the
other party, or on actual notice of the Order, whichever is sooner. This Order shall remain in
effect until further order of the court, or the entry of a Decree of Dissolution, Annulment, or
Legal Separation.
3. ORDER TO PETITIONER: You must serve a copy of this Order upon the Respondent,
along with a copy of the Petition for Dissolution, Annulment or Legal Separation, the
Summons, and other required court papers.
4. WARNING: This is an official Court Order. If you disobey this Order, the court may find
you in contempt of court. You may also be arrested and prosecuted for the crime of interfering
Case Number: S1100DO2
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with judicial proceedings and any other crime you may have committed by disobeying this
Order.
5. LAW ENFORCEMENT: You or your spouse may file a certified copy of this Order with
your local law enforcement agency. You may obtain a certified copy from the Clerk of the
Court that issues this Order. If any changes are made to this Order and you have filed a
certified copy of this Order with your local law enforcement agency, you must notify them of
the changes.
6. DESCRIPTION OF THE PARTIES:
Petitioner:
Name:
Gender:
Male Female
Height:
Weight:
Date of Birth:
Respondent:
Name:
Gender:
Male Female
Height:
Weight:
Date of Birth:
GIVEN UNDER MY HAND AND SEAL OF THE COURT
Date
Amanda Stanford
Clerk of the Superior Court
By
Deputy Clerk
Case Number: S1100DO2
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Name of Person Filing:
Telephone Number:
Email Address:
ATLAS Number (if applicable)
Representing Self (No Attorney)
or Represented by Attorney
If Attorney, Bar Number:
SUPERIOR COURT OF ARIZONA
PINAL COUNTY
CASE NUMBER:
S1100DO2
Name of Petitioner
SENSITIVE DATA SHEET
(CONFIDENTIAL RECORD)
Name of Respondent
HONORABLE:
Fill out. File with Clerk of Court. Social Security Numbers should appear on this
form only and should be omitted from other court forms. Access Confidential
pursuant to A.R.F.L.P. 43(G)(1).
A.
Personal Information:
Petitioner
Respondent
Name
Gender
Male or Female
Male or Female
Date of Birth (Month/Day/Year)
Social Security Number
Driver’s License Number
WARNING: DO NOT INCLUDE MAILING ADDRESS ON THIS FORM IF
REQUESTING ADDRESS PROTECTION
Mailing Address
City, State, Zip Code
Contact Phone
Email Address
Current Employer Name
Employer Address
Employer City, State, Zip Code
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Employer Telephone Number
Employer Fax Number
B.
Child(ren) Information:
Child Name
Gender
Child Social Security Number
Child Date of Birth
Clerk of Court Issued:
*For Court Use Only. NOT Public Record.
Do NOT Provide a Copy of This Document to The Other Party.
Case Number: S1100DO2
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Arizona Superior Court, Pinal County
Family Court Cover Sheet
CASE NUMBER
S1100DO2
Judge
ATLAS NUMBER(S)
PETITIONER’S NAME AND
ADDRESS
RESPONDENT’S NAME AND
ADDRESS
Name:
Name:
Address:
Address:
City/State/Zip:
City/State/Zip:
Phone Number:
Phone Number:
Email Address:
Email Address:
DOB:
DOB:
PETITIONER’S ATTORNEY
EMERGENCY ORDER SOUGHT
Name/State Bar #:
Order of
Protection
Address:
Temporary Order
City/State/Zip:
Other
Phone Number:
(Specify)
Do you or the other party need an
interpreter?
FEES: PAID NOT PAID - REASON
Yes No
Political Subdivision/Government
Agency
If yes, what language:
Deferred
Waived
ACTION REQUESTED: Check Only One
Box
DISSOLUTION (Divorce)
With Children
Without Children
Legal Separation
Paternity/Maternity
Annulment
Legal Decision-Making
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Order of Protection
Foreign Judgment
Domesticated Decree
Foreign Judgment for Legal Decision-
Making
Establish Support
Habeas Corpus
Visitation
Emergency Order of Protection
Other
(Specify)
I receive or have received public assistance which may include AFDC, TANF, or AHCCS for my
child(ren) or me.
Yes No
I have a case with the Division of Child Support Enforcement.
Yes No
If yes, list the case number(s)
_________________________________________________________________
Do you currently have ANY other Pinal County Superior Court cases?
Yes No
If yes, list the case number(s)
_________________________________________________________________
Have you ever had ANY other Pinal County Superior Court cases?
Yes No
If yes, list the case number(s)
_________________________________________________________________
PETITIONER'S DECLARATION OF INFORMATION FOR
CONCILIATION COURT
The wife is pregnant: Yes No
The respondent is being served by publication: Yes No
Please enter the number of children under the age of 18 of either or both parties who are in Legal
Case Number: S1100DO2
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Decision-Making of either or both parties:
NAMES OF MINOR CHILDREN &
DATE OF BIRTH:
NAMES OF MINOR CHILDREN &
DATE OF BIRTH:
There is an agreement as to the parenting arrangements of the minor children:
Yes No
To the best of my knowledge, all information is true and correct.
Attorney / Pro Per Signature
(If no attorney, your signature is required)
NOTICE
Effective September 8, 1992 and pursuant to Superior Court (Pinal County), Administrative Order
No. 92-15, the Superior Court requires that a "Cover Sheet", which categorizes the cause of action,
accompany any new action filed with the Superior Court in Pinal County. PLEASE DO NOT
INCLUDE THIS FORM WITH CASES THAT HAVE ALREADY BEEN FILED. This
form can only be processed at the time of filing New Complaints and Petitions.
Revised 6/22/09
Case Number: S1100DO2
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Name of Person Filing:
Street Address:
City, State, Zip Code:
Telephone Number:
Email Address:
ATLAS Number (if applicable):
Representing Self (No Attorney) or Represented by Attorney
If Attorney, Bar Number:
SUPERIOR COURT OF ARIZONA
PINAL COUNTY
CASE NUMBER:
S1100DO2
Name of Petitioner
(Leave Blank)
PETITION FOR DISSOLUTION OF
A NON-COVENANT MARRIAGE
(DIVORCE) WITH MINOR
CHILDREN
Name of Respondent
HONORABLE:
(Leave Blank)
SERVICE BY PUBLICATION:
If Respondent is served by publication and is not personally served, this Court may be unable to
make a legal order with respect to issues of child support, medical and dental insurance, payments,
expenses for the minor child(ren), community property or debt, or spousal maintenance/support.
The Court reserves jurisdiction until personal service is made upon Respondent to consider the
maintenance/support of either spouse, the disposition of community property or debts, child
support, and any other relief requested in the Petition or orders deemed necessary by the court.
GENERAL INFORMATION
Information about me, the Petitioner:
Name:
Address:
Date of Birth:
Job Title:
How long you have lived in Arizona:
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Information about my spouse, the Respondent:
Name:
Address:
Date of Birth:
Job Title:
How long the Respondent has lived in Arizona:
Information about my marriage:
Date of Marriage:
Location of Marriage:
THIS IS A PETITION FOR A FINAL
“DECREE OF DISSOLUTION OF MARRIAGE WITH MINOR CHILDREN.”
This Court has jurisdiction over the parties under the law, and the provisions of this Petition are
fair and reasonable under the circumstances and are in the best interests of the minor child(ren) as
to legal decision-making, parenting time, and support.
*These statements (1-3) must be true and the boxes must be checked for your case to
proceed using this paperwork.
1. *90 Day Requirement
At the time this action is filed, the Petitioner and/or the Respondent has lived in Arizona
for more than 90 days, or had been stationed in Arizona while a member of the United States
Armed Forces for more than 90 days.
2. *Conciliation Court
You may request a free meeting with yourself, the other party and a counselor to determine if
divorce is the right decision for you. You do not need the other party’s consent to request this
meeting. Please contact Family Services of Conciliation Court at 520.866.7349 for more
information.
We have tried to resolve our problems through Conciliation Services OR going to
Conciliation Services would not work.
3. *Irretrievably Broken
The marriage is irretrievably broken and there is no hope of reconciliation.
4. Covenant Marriage
The marriage is NOT a covenant marriage.
The marriage is a covenant marriage. (See Arizona Revised Statutes 25-901 and following).
Case Number: S1100DO2
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5. Pregnancy
Neither spouse is pregnant.
Wife is pregnant and the other party is the natural father of the child.
Wife is pregnant and the other party is not the natural father of the child.
6. Paternity
INSTRUCTIONS: If any of the minor children, common to the parties, were born
BEFORE your marriage, check the box and list the name(s) and date of birth(s) of those
children. If all of your children were born during the marriage, skip this question and continue
to #7.
Husband is the natural father of the following child(ren) born to the parties BEFORE the
marriage:
Name(s) Date of Birth(s)
7. Domestic Violence
INSTRUCTIONS: Domestic violence may affect a request for legal decision-making. Check
the relevant box below.
Domestic violence has not occurred during this marriage.
Significant domestic violence occurred during this marriage.
Domestic violence has occurred during this marriage. Even though domestic violence has
occurred, it was not significant or committed by both parties and joint legal decision-making is
in the best interest of the minor child(ren) because:
8. Substance Abuse
INSTRUCTION: Substance abuse may affect a request for legal decision-making. Check the
relevant boxes below.
Case Number: S1100DO2
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Neither party has abused drugs or alcohol or has been convicted of a drug offense or drug
violation within the twelve months before the Petition was filed.
Petitioner has abused drugs or alcohol or has been convicted of a drug offense or drug
violation within the twelve months before the Petition was filed.
Respondent has abused drugs or alcohol or has been convicted of a drug offense or drug
violation within the twelve months before the Petition was filed.
9. Minor Children
INSTRUCTIONS: List all children under the age of 18 that are common to you and the other
party. Here, it does not matter whether they were born before or during the marriage. List all
addresses where the child(ren) have lived within the past six months. Use and attach additional
pages if necessary.
Child’s Name: Birth Date:
Addresses for the last 6 months:
Address: Length of time at address
Address: Length of time at address
Child’s Name: Birth Date:
Addresses for the last 6 months:
Address: Length of time at address
Address: Length of time at address
Child’s Name: Birth Date:
Addresses for the last 6 months:
Address: Length of time at address
Address: Length of time at address
Child’s Name: Birth Date:
Addresses for the last 6 months:
Address: Length of time at address
Address: Length of time at address
10. Spousal Maintenance: Money paid from one spouse to the other spouse after the divorce,
also known as alimony.
INSTRUCTIONS: Check the box if you do not want either spouse to receive spousal
maintenance.
Neither party is entitled to spousal maintenance
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INSTRUCTIONS: If you want the other party to pay you spousal maintenance, check the
box that says Petitioner. If you want to pay the other party spousal maintenance, check the
box that says Respondent”.
Petitioner OR Respondent is entitled to spousal maintenance because s/he
INSTRUCTIONS: You must also check at least one of the following four boxes
explaining why spousal maintenance is appropriate.
Lacks sufficient property, including given to him or her as part of this divorce, to
provide for his or her reasonable needs.
Is unable to be self-sufficient through appropriate employment or is the custodian of
a child whose age or condition is such that the custodian should not be required to seek
employment outside the home or lacks earning ability in the labor market adequate to be
self-sufficient.
Contributed to the educational opportunities of the other spouse.
Had a marriage of long duration and is of an age that may preclude the possibility of
gaining employment adequate to be self-sufficient.
11. Child Support Deviation
INSTRUCTIONS: Within this packet you will find a child support calculator form for the
Parent's Worksheet. You must fill out the child support calculator entry form online; there are
instructions in this packet. Fill this section out ONLY if you want a different amount of
child support than is given on the child support calculator.
First, fill in the amount the child support calculator gives.
Second, give reasons why the amount of child support should be different.
Third, fill in the amount of child support that should be ordered.
The amount of child support based on the Parents Worksheet for Child Support is $ ,
however, this amount is inappropriate or unjust and not in the best interest of the child(ren)
because
The amount of child support should be $ .
REQUESTS THE COURT TO ORDER
1. Marriage is Dissolved
The marriage of the parties is dissolved and the parties are restored to the legal status of
single persons.
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2. Parenting Plan
There is a parenting plan filed with this Petition, which addresses parenting time and legal
decision-making.
3. Name Change Optional
INSTRUCTIONS: Check this box only if you want to use your maiden or former name. If
you check the box, also check the box next to whoever is changing his or her name, either
Petitioner or Respondent. In the first blank, write out the complete married name, including
the middle name. In the second blank, write out the complete maiden name/former name.
The name of the Petitioner OR Respondent, whose complete married name is:
is restored to: (List the complete legal name or maiden name as before the marriage)
Children’s Names Optional
INSTRUCTIONS: If you are requesting to change your child(ren)’s last name(s), list each
child’s current legal name and the new name you are requesting.
The names of one or more of the minor children shall be changed as follows:
Current Legal Name New Name
4. Financial Information Exchanges
INSTRUCTIONS: Under Arizona law it is REQUIRED that parties with minor children
exchange financial information every 24 months.
The parties shall exchange financial information (tax returns, spousal affidavits, earning
statements and/or other related financial statements) every twenty-four months.
5. Child Support
Neither party shall pay child support until further Order of the court.
There is an Order for Child Support dated (date) from .
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To my knowledge there is no child support order for the minor child(ren) and the court
should order child support in this case along with legal decision making (custody), and
parenting time.
INSTRUCTIONS: Tell the court who should pay child support by checking either Petitioner
or Respondent. On the space provided, enter the amount calculated on the Parents Worksheet
for Child Support OR the amount previously requested. Choose whether you want the child
support payments to begin the month after the Decree is signed by a judge or on a previous
date.
Petitioner OR Respondent shall pay child support to the other party in the amount of
$ per month, beginning
the month following the date the Decree is signed by the judge
OR
(date)
until further Order of the court. Child Support is based on the information in the Parent’s
Worksheet for Child Support calculated pursuant to the Arizona Child Support Guidelines. All
child support payments shall be made by wage assignment (if applicable) through the Support
Payment Clearinghouse (P.O. Box 52107, Phoenix, AZ 85072-2107), and must include the
statutory fee by the Income Withholding Order or the Order of Assignment.
Past Support
There is a request for past support. There is not a request for past support.
Petitioner OR Respondent made voluntary/direct support payments that need to be
taken into account if past support is requested.
Petitioner OR Respondent owes past support for the period between:
the date this petition was filed and the date current child support is ordered.
OR
the date the parties started living apart, but not more than three years before the
date this petition was filed and the date current child support is ordered
6. Medical, Dental, and Vision Insurance for Minor Children
INSTRUCTIONS: Tell the court who should be paying for medical, dental, and vision
insurance for the children.
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Petitioner is responsible for providing:
Medical Dental Vision
Respondent is responsible for providing:
Medical Dental Vision
The child(ren) are on AHCCCS. Both parents are responsible for providing medical
insurance for the minor children as soon as it becomes accessible and available at a reasonable
cost, as neither parent currently has the ability to obtain such insurance.
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.
7. Uncovered Medical, Dental, and Vision Expenses
INSTRUCTIONS: Tell the court who will pay for medically necessary (as defined by Internal
Revenue Service Publication 502) uncovered medical, dental, and vision expenses such as co-
pays. You can request that each party pays a percentage of any uncovered medical expenses or
that you each pay in proportion to your respective incomes.
All reasonable uncovered and/or uninsured medical, dental, vision care, prescription and other
health care charges for the minor child(ren), including co-payments shall be allocated as follows:
Petitioner and Respondent are to pay in proportion to their respective incomes according
to the child support calculator.
OR
Petitioner to pay %
Respondent to pay %
8. Tax Exemptions
INSTRUCTIONS: The child support calculator provides guidelines regarding who should
claim the child(ren) as tax exemptions each year. If you wish to deviate from these guidelines
check the “other” box and write in what you are requesting.
The parents shall claim the child(ren) as income tax dependency exemptions on federal and
state tax returns as follows:
Petitioner OR Respondent will claim the children every year.
Petitioner OR Respondent will claim the children every odd year.
Petitioner OR Respondent will claim the children every even year.
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Other:
The parent required to pay child support is only entitled to claim the child(ren) as an income
tax dependency exemption if that parent has paid all of the child support due and owing for
the year.
9. Spousal Maintenance
INSTRUCTIONS: Earlier in the Petition you told the court whether or not one of the parties
should receive spousal maintenance from the other party. Here, you tell the court how much
per month and for how long that spouse should receive spousal maintenance or if neither party
should pay spousal maintenance to the other party.
Neither party to pay spousal maintenance to the other party.
OR
Petitioner shall receive spousal maintenance from Respondent in the amount of $
per month and the payments to continue until the receiving party is remarried or deceased.
OR
Petitioner shall receive spousal maintenance from Respondent in the amount of $
per month and the payments to continue until the receiving party is remarried or deceased or
for months, whichever comes first.
OR
Respondent shall receive spousal maintenance from Petitioner in the amount of $
per month and the payments to continue until the receiving party is remarried or deceased.
OR
Respondent shall receive spousal maintenance from Petitioner in the amount of $
per month and the payments to continue until the receiving party is remarried or deceased or
for months, whichever comes first.
INSTRUCTIONS: Do you want either the other party or yourself to be able to modify spousal
maintenance in the future? If so, check the first box. If not, check the second box.
Spousal maintenance shall be modified in accordance with Arizona law.
Spousal maintenance shall NOT be modifiable for any reason.
10. Debt
INSTRUCTIONS: You must identify all of your debt as either community debt or separate
debt. Community debts are debts that you or the other party incurred during the marriage.
Separate debts are debts that you or the other party incurred before the marriage.
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a. Community Debt: Community debts are debts incurred by either party during the
marriage. You should see a lawyer about how to divide secured and unsecured debts.
Community debts shall be divided as follows:
INSTRUCTIONS: Check this box if you do not have any community debt.
My spouse and I do not have any community debts.
INSTRUCTIONS: Check this box if you have community debt. List all community debts, the
total owed, and the amount OR percentage to be paid by each party. If you need more space
attach an additional sheet of paper and check the box The list continues on attached page.”
My spouse and I have community debts which shall be divided as follows:
Amount or
Percent to be
paid by Petitioner
Amount or
Percent to be
paid by Respondent
Creditor Name
Amount Owed
The list continues on attached page.
Petitioner is ordered to pay all debts unknown to Respondent.
Respondent is ordered to pay all debts unknown to Petitioner.
Each party is ordered to pay his or her debts incurred since (date) .
Any debts or obligations incurred by either party before the date of separation, that are not
identified in the list above or attached, shall be paid by the party who incurred the debt or
obligation and that party shall indemnify and hold the other party harmless from such debts.
b. Separate Debt: Separate debts are debts incurred before the marriage. Check ONLY
one of the three boxes. If you check the last box, list your separate debts, the total owed,
and the amount or percentage to be paid by each party. Separate debts shall be divided
as follows:
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Neither my spouse nor I have any separate debt.
My spouse and/or I have separate debts and Husband must pay his separate debt and Wife
must pay her separate debt.
My spouse and/or I have separate debts and they shall be divided as follows:
Amount or
Percent to be
paid by Petitioner
Amount or
Percent to be
paid by Respondent
Creditor Name
Amount Owed
11. Property
IMPORTANT
: If there is a piece of property with a debt attached such as a car with a
loan, you must list the property under Property” and the debt under “Debt”.
INSTRUCTIONS: You must identify all of your property as either community property or
separate property. Community property is property that you acquired during the marriage,
but was not gifted to either you or the other party and that was not inherited. Separate
property is property that you acquired before the marriage, property that was gifted to either
you or the other party, or that was inherited.
a. Community Property: Community Property is property that was acquired during the
marriage, which was not gifted to one party or inherited. Community Property shall be
divided as follows:
My spouse and I did not acquire any community property during the marriage.
OR
My spouse and I acquired community property during the marriage and it should be
divided as follows: Include vehicles on this list.
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Description of Property
Awarded to
Petitioner
Awarded to
Respondent
Value
$
$
$
$
$
$
$
This list continues on attached page
b. Separate Property: Separate property is property acquired before the marriage,
property that was gifted to one party, or that was inherited. Separate Property to be
divided as follows:
My spouse and I do not have separate property.
My spouse and/or I have separate property and each party shall be awarded his or her
own separate property.
My spouse and/or I have separate property, which shall be divided as follows:
Description of Property
Awarded to
Petitioner
Awarded to
Respondent
Value
$
$
$
$
$
$
$
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c. Real Property: Real property is the house and land you own. You can ask the court to
give you the home, to give the home to the other party, or to sell the home and divide
any loss or proceeds. Write the complete address of the property under real property
located at”. Most property has a legal description such as LOT 77, PINE TREE
ACRES, according to Book 111 of Maps” which appears on your deed papers. You
should use this description. A cemetery plot is considered real property.
My spouse and I do not have real property.
My spouse and I have real property located at:
valued at approximately $ . The legal description of the property is (this information is
needed prior to an order being entered regarding real property):
The real property shall be sold and any loss or proceeds divided with Petitioner being
awarded % and Respondent being awarded %.
The real property shall be awarded to Petitioner.
The real property shall be awarded to Respondent.
The party being awarded the real property will refinance the real property solely in his
or her name on or before (insert date). If unsuccessful, the real property will be
INSTRUCTIONS: Complete only if there is a second property.
My spouse and I do not have additional real property.
My spouse and I have additional real property located at:
valued at approximately $ . The legal description of the property is (this information is
needed prior to an order being entered regarding real property):
The real property shall be sold and any loss proceeds divided with Petitioner being
awarded % and Respondent being awarded %.
The real property shall be awarded to Petitioner.
The real property shall be awarded to Respondent.
The party being awarded the real property will refinance the real property solely in his
or her name on or before (insert date). If unsuccessful, the real property will be
.
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d. Retirement:
WARNING: You should see a lawyer about your retirement accounts. If you do not see a
lawyer regarding these assets, you risk losing any interest you have in these plans and/or
benefits. There are certain documents the plan administrator must have. It is recommended
that you consult with a lawyer to help you prepare these documents.
INSTRUCTIONS: A retirement account is considered property. Any part of the retirement
that grew during the marriage is community property. Any part of the retirement that existed
before the marriage, is separate property. You do not need to list the retirement under
Property” if you list it here.
IMPORTANT: If you want to divide the retirement account(s) you must see an attorney
about a document called a Qualified Domestic Relations Order (QDRO) or a Court Order
Acceptable for Processing (COAP). A QDRO or a COAP is a very specialized legal document.
It is recommended that you seek professional assistance to prepare the QDRO or COAP. Do
not have this done until a judge signs your Decree.
Neither party has a retirement account.
Each party waives and gives up his/her interest in any and all retirement benefits, pension
plans, or other deferred compensation of the other party.
Divide retirement accounts as follows:
12. Taxes
INSTRUCTIONS: This question is asking how you and the other party have filed taxes during
the time you were married.
a. For previous calendar years, pursuant to IRS rules and regulations, the parties have filed or
will file:
INSTRUCTIONS: If you and the other party ever filed jointly, check this box and list the tax
years you filed jointly.
Joint federal and state income tax returns for (years) and hold each other
harmless from half of all income taxes and costs, if any, and each party will share equally in tax
refunds, if any.
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INSTRUCTIONS: If you and the other party ever filed separately, check this box and list
the tax years you filed separately.
Separate federal and state income tax returns for (years) .
Other:
This calendar year and continuing thereafter, each party will file separate federal and state
income tax returns.
Each party shall give the other party all necessary documentation to file all tax returns, unless
that information is protected.
Other information and request(s) regarding taxes:
13. Other Requests:
INSTRUCTIONS: Use this space to ask the court for anything that you want the court to
do but have not asked for yet.
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OATH OR AFFIRMATION AND VERIFICATION:
I swear or affirm that the information on this document is true and correct under penalty
of perjury.
Date
Signature
State of Arizona )
)
County of )
Subscribed and sworn (or affirmed) before me this
day of
,
20
(Day)
(Month)
(Year)
by
(Name of Signer)
(Affix notary seal here)
Notary Public (Notary’s Signature)
Case Number: S1100DO2
Revised 10.04.18
SERVICE
OF COURT PAPERS
FAMILY COURT CASES ONLY
(When Parties AGREE to all terms of the Divorce)
PINAL COUNTY
HOW TO SERVE NOTICE AS
REQUIRED OR PERMITTED BY LAW
STEP 2
(Please complete step two before proceeding to the next step)
INSTRUCTIONS AND FORMS
Provided as a Public Service by
AMANDA STANFORD
Clerk of the Superior Court
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HOW TO SERVE COURT PAPERS ON THE OTHER PARTIES
TABLE OF CONTENTS
This packet contains general information, court forms, instructions and procedures for
serving
court papers, delivering court papers as permitted or required by law. Use only the
forms that apply to the method of service you have chosen. Do NOT copy or file information,
instruction or procedures pages with the Court.
Order
Title
# of Pages
1
Table of Contents (this page)
1
2
Family Court Acceptance of Service
3
3
How to Serve the Other Party by Certified Mail
1
4
Affidavit Supporting Service by Certified Mail
2
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.
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Name of Person Filing:
Street Address:
City, State, Zip Code:
Telephone Number:
Email Address:
ATLAS Number (if applicable)
Representing Self (No Attorney)
or Represented by Attorney
If Attorney, Bar Number:
SUPERIOR COURT OF ARIZONA
PINAL COUNTY
CASE NUMBER:
S1100DO2
Name of Petitioner
FAMILY COURT
ACCEPTANCE OF SERVICE
A.R.F.L.P. RULE 40
Name of Respondent
HONORABLE:
Check the box to indicate each document you received. Do not check the box unless you received
the document listed beside it. If your case is not one of the types listed, list the type of case and the
documents you received from the other party under “Other Type Case” on the next page.
1. BY SIGNING THIS DOCUMENT, I STATE UNDER OATH OR AFFIRMATION
THAT I HAVE RECEIVED AND ACCEPTED THE LEGAL PAPERS INDICATED
(CHECKED) BELOW
DIVORCE (OR
ANNULMENT)
WITH CHILDREN
Petition
Summons
Preliminary Injunction
Health Insurance Notice
Parent Info. Program
Notice
Notice to Creditors
LEGAL SEPARATION
WITH CHILDREN
Petition
Summons
Preliminary Injunction
Health Insurance Notice
Parent Info. Program
Notice
Notice to Creditors
Affidavit Regarding
Minor Children
TEMPORARY ORDERS
Motion for Temporary
Order
Order to Appear
Temporary Orders
Affidavit of Financial Info.
Child Support Worksheet
Parenting Plan
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Affidavit Regarding Minor
Children
Parenting Plan
Child Support Worksheet
Parenting Plan
Child Support Worksheet
DIVORCE (OR
ANNULMENT) WITHOUT
CHILDREN
Petition
Summons
Preliminary Injunction
Health Insurance Notice
Notice to Creditors
LEGAL SEPARATION
WITHOUT CHILDREN
Petition
Summons
Preliminary Injunction
Health Insurance Notice
Notice to Creditors
PATERNITY (TO
ESTABLISH)
Petition
Summons
Parent Info. Program Notice
Affidavit Regarding Minor
Children
Parenting Plan
Child Support Worksheet
CHILD LEGAL DECISION-MAKING,
PARENTING TIME, SUPPORT
(to establish when paternity already legally
established)
Petition
Summons
Parent Info. Program Notice
Affidavit Regarding Minor Children
Parenting Plan
Child Support Worksheet
CHILD SUPPORT
(to establish when paternity already legally
established)
Petition
Order to Appear
Child Support Worksheet
ENFORCEMENT
Petition Order to Appear
MODIFY CHILD SUPPORT 15% OR
MORE
(“Simplified Mod”)
Petition to Modify
Parents Worksheet for Child Support
Blank Request for Hearing
MODIFY SPOUSAL MAINTENANCE
OR
SPOUSAL
AND
CHILD SUPPORT
(“Standard Mod”)
Petition to Modify Support Order
Order to Appear
Affidavit of Financial Information
MODIFY CHILD SUPPORT (“Standard
Mod”)
Petition to Modify Child Support Std.
Process
MODIFY CHILD LEGAL DECISION-
MAKING &/OR PARENTING TIME
AND SUPPORT
Petition to Modify
Case Number: S1100DO2
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Affidavit of Financial Information
Order to Appear
Parents’ Worksheet for Child Support
Notice of Filing for Modification of Legal
decision-making
Affidavit Regarding Minor Children
STOP ORDER OF ASSIGNMENT/
INCOME WITHHOLDING ORDER
Petition to Stop Order of Assignment
Blank Request for Hearing
MODIFY (Change) ORDER OF
ASSIGNMENT/
INCOME WITHHOLDING ORDER
Petition to Modify Order of Assignment
Blank Request for Hearing
LIST OTHER CASE TYPE HERE: (Example: “Annulment”)
________________________________________
(Below, list name of each document you received: Example: “Petition for Annulment”,
“Summons”, etc.)
2. ACCEPT AND WAIVE FORMAL SERVICE. I waive formal service of process by a process
server or sheriff. I understand accepting these papers is the same as if I were personally served
under Arizona Law [A.R.F.L.P. Rule 40 (F)]
3. RESPONSE DEADLINE. I am aware that accepting service of these court papers and signing
this paper does not affect my right or obligation to file a written Response or Answer to this
action if I do not agree with any relief asked for in the Petition. I understand I must Respond or
Answer within 20 days from the day I signed the original of this Acceptance of Service if I
accepted service in Arizona, or 30 days if I received the papers somewhere other than in Arizona.
4. DEFAULT JUDGMENT, ORDER OR DECREE. I understand that if I do not appear and
defend in this action in court, within the time allowed by law, that I may lose my right to be heard
in this case. I understand that failure to Respond or Answer could result in the court giving the
other party any and all things requested in his or her legal papers, through a Default Judgment,
Order or Decree.
Case Number: S1100DO2
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5. RESTORE NAME. (ONLY in Divorce, Legal Separation or Annulment Cases.)
My complete married name is: (Complete ONLY if you want to change your name)
I want my legal name restored to: (List complete maiden name or legal name before
this marriage)
BY SIGNING BELOW, I swear or affirm that I have read and understand the contents of
this document and that I have received and accepted the legal documents indicated above.
Date
Signature
State of Arizona )
)
County of )
Subscribed and sworn (or affirmed) before me this
day of
,
20
(Day)
(Month)
(Year)
by
(Name of Signer)
(Affix notary seal here)
Notary Public
(Notary’s Signature)
Case Number: S1100DO2
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PROCEDURES
How to Serve Court Papers by Certified Mail
USE THIS PROCEDURE ONLY after you have filed your papers with the court.
STEP 1: GO TO THE POST OFFICE and tell the clerk you would like to mail the
other party a letter as follows:
Certified Mail, and
Deliver to Addressee Only, and
Restricted Delivery, and
Return Receipt Requested, and
Pay the postage.
STEP 2: WAIT for green receipt to be returned with the other party’s signature. When
you get the green receipt, note the date the other party received and signed for
the papers.
STEP 3: PAPERS FOR THE COURT
COMPLETE: Original of
“Affidavit of Service by Certified Mail.”
Fill in ALL information requested on the form before proceeding. Be
sure you fill in the date the other party received the papers. If you are
unsure of the date, use the date you received the return receipt card. If
you fail to list a date, the court may not process your papers and your
case may be delayed.
ATTACH: You must attach the original green receipt to the Affidavit
to prove how you served the other party.
COPY: Make yourself a copy of the
“Affidavit of Service by Certified
Mail”
and a copy of the green receipt to keep for your files.
STEP 4: FILE PAPERS WITH THE COURT. File the Original
“Affidavit of
Service by Certified Mail”
and the original green receipt with the Clerk of the
Court.
STEP 5: COUNT. Note the date the other party was served the papers and start
counting the days the other party has to file a Response or Answer. (When
counting the days, start counting with the day after the other party signed the
green receipt.)
DO NOT BRING CHILDREN TO COURT
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Name of Person Filing:
Street Address:
City, State, Zip Code:
Telephone Number:
Email Address:
ATLAS Number (if applicable)
Representing Self (No Attorney)
or Represented by Attorney
If Attorney, Bar Number:
SUPERIOR COURT OF ARIZONA
PINAL COUNTY
CASE NUMBER:
S1100DO2
Name of Petitioner
AFFIDAVIT OF SERVICE BY
CERTIFIED MAIL
Name of Respondent
HONORABLE:
1. I am familiar with the facts stated in this Affidavit, and I make this Affidavit to show that I have
served the court papers on the other party by certified mail, postage prepaid, return receipt requested,
pursuant to Arizona Rules of Civil Procedure, Rule 4.2(c).
Person served (name of other party):
Address where other party was served:
Date of receipt by the other party:
Date of return of receipt to sender:
2. The following documents were sent to the other party by certified mail (List all the documents
sent to the other party):
These court papers were received by the other party as shown by the
original RETURN
receipt that
is attached to this Affidavit.
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Date
Signature
State of Arizona )
)
County of )
Subscribed and sworn (or affirmed) before me this
day of
,
20
(Day)
(Month)
(Year)
by
(Name of Signer)
(Affix notary seal here)
Notary Public (Notary’s Signature)
ATTACH THE ORIGINAL MAIL RETURN RECEIPT HERE
Case Number: S1100DO2
Revised 12.24.18
CONSENT DECREE
FOR DIVORCE OF MARRIAGE WITH CHILDREN
(When Parties AGREE to all terms of the Divorce)
PINAL COUNTY
NON-COVENANT MARRIAGE
To Get A Divorce Order/Consent Decree
STEP 3
(Please complete step three before proceeding to the next step)
INSTRUCTIONS AND FORMS
Provided as a Public Service by
AMANDA STANFORD
Clerk of the Superior Court
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CONSENT DECREE FOR DISSOLUTION
FOR A NON-COVENANT MARRIAGE WITH CHILDREN
This packet contains court forms and instructions to get a decree of divorce for a non-
covenant marriage with children. The documents should appear in order as follows.
Order
Title
# of Pages
1
Table of Contents (this page)
1
2
What the Decree Means & Utilizing a Consent Decree
2
3
Procedures: How to file a Consent Decree
1
4
Consent Decree of Dissolution with Children
16
5
Child Support Order
9
6
Income Withholding for Support (Instructions and Forms)
12
7
Parenting Plan
11
You have permission to use these documents 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.
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Decree of Dissolution (Divorce) For a Non-Covenant Marriage with Minor Children
What the Decree Means to You. The Decree is the Court Order that legally ends your marriage.
The Decree, once the judge or commissioner has signed it, is important because it determines the
rights and responsibilities of both you and your ex-spouse. It tells the parties what they can and cannot
do. If either party does not do what the Decree tells him/her to do, then the other party may ask the
court for help. This is a very important document. Once it has been signed by the judge, your rights
and responsibilities are affected forever.
Failure to do what the Decree tells you to do could get you into trouble with the court. This
does not mean that the court will police whether you are following the Decree. It does mean you or
your ex- spouse can request a Contempt Order or an Order to enforce parts of the Decree if you or
your ex- spouse fails to do what the Decree tells you to do.
Getting Your Divorce Finalized. Before your divorce can become final, a judicial officer must sign
what we call a Decree of Dissolution of Marriage. The Decree tells you who will get the property, who
pays the debts, who gets Legal Decision-Making, who pays support and so forth.
Divorce by Default. If you have a Default Hearing, you must repeat as closely as possible
what you requested in your Petition. You cannot mark something different in the Decree from
what you asked for in the Petition, unless your spouse has provided written consent. If you try to do
this, the judicial officer will not sign the Decree. If you want to change your requests to the court, you
must file an amended Petition. It is a good idea to have your Petition handy when you fill out your
Decree.
The Decree. Fill out the Decree before you go to your hearing or before you give it to the judge to
sign. Do not fill in the judge's signature and date. If the judge disagrees with anything you have written,
he or she will change it before signing the Decree.
Criteria for Utilizing a Consent Decree
You or your spouse filed a petition for Divorce or Petition for Legal Separation AND,
You do not have a "covenant" marriage AND,
You and your spouse agree to all terms of the divorce or legal separation such as division of
property and debt, whether there will be spousal maintenance (alimony) and if so, how much,
and if there are minor children, you agree on all terms of legal decision-making, support and
parenting time AND,
You and your spouse will provide your notarized signatures on the "Consent Decree" to
indicate your agreement on all terms; AND,
If your case involves minor children, you and your spouse have attended, or will attend, the
Parent Information Program before you file a Consent Decree;
DO NOT USE SIGN THE CONSENT DECREE
PAGE (#15) IF: You disagree on any terms of the divorce or legal separation
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PROCEDURES
How to File a Consent Decree with the Court for Dissolution of a Non-Covenant
Marriage (Divorce) With Minor Children
IMPORTANT: The Consent Decree must be submitted 61 days from the date of
service upon the Respondent.
STEP 1: Complete the form TYPE OR PRINT IN BLACK INK
Both the Petitioner and Respondent will need to sign and date the Consent
Decree in front of a Notary Public.
STEP 2: Make 2 Copies of the document after they have been filled out and
signed by a
Notary Public.
STEP 3: SEPARATE YOUR DOCUMENTS INTO THREE (3) SETS:
SET
1
Origin
a
l
s
for Cl
erk
of
Co
u
rt
SET
2
C
opi
es
for Spou
se
SET
3
C
opi
es
for You
IF YOU ARE FILING FOR DIVORCE WITH CHILDREN:
Also provide the following documents:
1.
Child Support Order
2.
Income Withholding Order
3.
A copy of the Parenting Plan to attach to the Consent Decree
You will need to obtain two (2) appropriate sized self-addressed stamped
envelopes. One envelope will need to be addressed to the Petitioner and the
additional envelope will need to be addressed to the Respondent.
STEP 4: SUBMIT THE PAPERS WITH THE CLERK OF THE SUPERIOR
COURT:
In Person:
Go to the Clerk of Court filing counters at one of our locations: You should go
to the Court at least two hours before it closes.
Visit our website for office locations or feel free to give us a call.
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Contact Information for all Offices
Toll Free: 888.431.1311 • Local: 520.509.3555 or 311 • Fax: 520.866.5320
www.coscpinalcountyaz.gov/office.html
By Mail: Clerk of the Superior Court
P.O. Box 2730
Florence, AZ
85132
STEP 5: The Consent Decree will then be sent to the Judges office for approval. If
approved, you
will receive your final Consent Decree in the Mail.
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Name of Person Filing:
Street Address:
City, State, Zip Code:
Telephone Number:
Email Address:
ATLAS Number (if applicable):
Representing Self (No Attorney) or Represented by Attorney
If Attorney, Bar Number:
SUPERIOR COURT OF ARIZONA
PINAL COUNTY
CASE NUMBER: S1100DO2
Name of Petitioner
CONSENT DECREE OF
DISSOLUTION OF MARRIAGE
(DIVORCE) WITH MINOR CHILDREN
Name of Respondent HONORABLE:
SERVICE BY PUBLICATION:
If Respondent was served by publication and was not personally served this Court may be unable
to make a legal order with respect to issues of child support, medical and dental insurance,
payments, expenses for the minor child(ren), community property or debt, or spousal
maintenance/support. The Court reserves jurisdiction until personal service is made upon
Respondent to consider the maintenance/support of either spouse, the disposition of
community property or debts, child support, and any other relief requested in the Petition or
orders deemed necessary by the court.
THE COURT FINDS:
1.
This case has come before this Court for a final
“Decree of Dissolution of Marriage
with Minor Children.”
The Court has taken all testimony needed to enter this Decree, or the
court has determined testimony is not needed to enter the Decree.
2.
This Court has jurisdiction over the parties under the law, and the provisions of this
Decree are fair and reasonable under the circumstances and are in the best interests of the minor
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child(ren) as to legal decision- making, parenting time, and support.
3.
90-Day Requirement:
At the time this action was filed, Petitioner or Respondent had
lived in Arizona for more than 90 days or had been stationed in Arizona while a member of the
United States Armed Forces for more than 90 days.
4.
Conciliation Court:
The provisions relating to the Conciliation Court either do not apply
or have been met.
5.
Irretrievably Broken:
The marriage is irretrievably broken and there is no hope of
reconciliation.
6.
Covenant Marriage:
The marriage is not a covenant marriage.
7.
Paternity:
INSTRUCTIONS:
If any of the minor children, common to the parties, were born
BEFORE
your marriage, check the box and list the name(s) and date of birth(s) of those children. If all of
your children were born during the marriage, skip this question.
Husband is the natural father of the following child(ren) born to the parties
BEFORE
the
marriage:
Name(s) Date of Birth(s)
8.
Domestic Violence:
INSTRUCTIONS:
Domestic violence may affect a request for legal decision-making. Check
the relevant box below.
Domestic violence has not occurred during this marriage.
Significant domestic violence occurred during this marriage.
Domestic violence has occurred during this marriage. Even though domestic violence has
occurred, it was not significant or committed by both parties and joint legal decision-making is
in the best interest of the minor child(ren) because:
Case Number: S1100DO2
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9.
Substance Abuse:
INSTRUCTION:
Substance abuse may affect a request for legal decision-making. Check the
relevant boxes below.
Neither party has abused drugs or alcohol or has been convicted of a drug offense or drug
violation within the twelve months before the Petition was filed.
Petitioner has abused drugs or alcohol or has been convicted of a drug offense or drug
violation within the twelve months before the Petition was filed.
Respondent has abused drugs or alcohol or has been convicted of a drug offense or drug
violation within the twelve months before the Petition was filed.
10.
Minor Children:
INSTRUCTIONS:
List
all
children under the age of 18 that are common to you and the other
party. Here, it does not matter whether they were born before or during the marriage. List all
addresses where the child(ren) have lived within the past six months. Use and attach additional
pages if necessary.
Child’s Name:
Birth Date:
Addresses for the last 6 months:
Address:
Length of time at address
:
Address:
Length of time at address
:
Child’s Name:
Birth Date:
Addresses for the last 6 months:
Address:
Length of time at address
:
Address:
Length of time at address
:
Child’s Name:
Birth Date:
Addresses for the last 6 months:
Case Number: S1100DO2
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Address:
Length of time at address
:
Address:
Length of time at address
:
Child’s Name:
Birth Date:
Addresses for the last 6 months:
Address:
Length of time at address
:
Address:
Length of time at address
:
11.
Spousal Maintenance:
Money paid from one spouse to the other spouse after the
divorce, also known as alimony.
INSTRUCTIONS:
Check this box if neither spouse will receive spousal maintenance.
Neither party is entitled to spousal maintenance
INSTRUCTIONS:
Check the box next to the person who will RECEIVE spousal
maintenance.
Petitioner OR Respondent
is entitled to spousal maintenance because s/he
INSTRUCTIONS:
You must also check at least one of the following four boxes
explaining why spousal maintenance is appropriate.
Lacks sufficient property, including given to him or her as part of this divorce,
to provide for his or her reasonable needs.
Is unable to be self-sufficient through appropriate employment or is the
custodian of a child whose age or condition is such that the custodian should not
be required to seek employment outside the home or lacks earning ability in the
labor market adequate to be self-sufficient.
Contributed to the educational opportunities of the other spouse.
Had a marriage of long duration and is of an age that may preclude the
possibility of gaining employment adequate to be self-sufficient.
Case Number: S1100DO2
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12.
Child Support Deviation
INSTRUCTIONS:
Within this packet you will find a child support calculator form for the
Parent's Worksheet. You must fill out the child support calculator entry form online; there are
instructions in this packet.
Fill this section out ONLY if the child support to be ordered is
a different amount than what is given on the child support calculator.
First, fill in the amount the child support calculator gives.
Second, give reasons why the amount of child support should be different.
Third, fill in the amount of child support that should be ordered.
The amount of child support based on the Parent’s Worksheet for Child Support is $______,
however, this amount is inappropriate or unjust and not in the best interest of the child(ren)
because
The amount of child support should be $ .
13.
Ability to Pay Child Support:
The court finds that the person responsible for paying
child support has the ability to pay the child support amount on the child support order attached
hereto and incorporated herein.
14.
Parent Information Program:
Petitioner has attended the Parent Information Program class.
Petitioner has not attended the Parent Information Program class and shall be denied any
requested
relief
to enforce or modify this Decree until Petitioner has completed the class.
Respondent has attended the Parent Information Program class.
Respondent has not attended the Parent Information Program class and shall be denied any
requested relief to enforce or modify this Decree until Respondent has completed the class.
15.
Supervised or No Parenting Time:
INSTRUCTIONS
: Check and complete only if supervised or no parenting time is ordered. If
supervised or no parenting time is ordered, reasons must be listed.
Supervised
parenting time between the minor child(ren) and Petitioner
OR
Respondent for
the following reasons:
Case Number: S1100DO2
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No Parenting Time
by
Petitioner
OR
Respondent is in the best interest of the
child(ren) for
the following reasons:
THE COURT ORDERS:
1.
Marriage is Dissolved
The marriage of the parties is dissolved and the parties are restored to the legal status of
single persons.
2.
Parenting Time Plan
There is a parenting time plan attached with this Petition which addresses parenting time
and legal decision-making.
3.
Name Change
Optional
INSTRUCTIONS:
Check this box only if you want to use your maiden or former name. If you
check the box, also check the box next to whoever is changing his or her name, either Petitioner
or Respondent. In the first blank, write out the complete married name, including the middle
name. In the second blank, write out the complete maiden name/former name.
The name of the Petitioner
OR
Respondent, whose complete married name is:
is restored to: (List the complete legal name or maiden name as before the marriage)
Children’s Names
Optional
INSTRUCTIONS:
If you are changing your child(ren)’s last name(s), list each child’s current
legal name and the new name you are requesting.
The names of one or more of the minor children shall be changed as follows:
Current Legal Name New Name
4.
Financial Information Exchanges
INSTRUCTIONS:
Under Arizona law it is REQUIRED that parties with minor children
exchange financial information every 24 months.
Case Number: S1100DO2
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The parties shall exchange financial information (tax returns, spousal affidavits, earning
statements and/or other related financial statements) every twenty-four months.
5.
Child Support
The Child Support Order is attached hereto and incorporated by reference.
This Court cannot make a legal order, without personal service on the Respondent, with respect
to issues of child support, or medical, dental and vision care insurance for the minor child(ren). The
court reserves jurisdiction to enter further orders at such time as the Court acquires personal
jurisdiction over the Respondent.
6.
Medical, Dental, and Vision Insurance for Minor Children
INSTRUCTIONS:
Tell the court who will be paying for medical, dental, and vision insurance
for the children.
Petitioner
is responsible for providing Insurance:
Medical
Dental
Vision
Respondent
is responsible for providing Insurance:
Medical Dental Vision
The child(ren) are on AHCCCS. Both parents are responsible for providing medical insurance
for the minor children as soon as it becomes accessible and available at a reasonable cost, as
neither parent currently has the ability to obtain such insurance.
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.
7.
Uncovered Medical, Dental, and Vision Expenses
INSTRUCTIONS:
Tell the court who will pay for medically necessary (as defined by Internal
Revenue Service Publication 502) uncovered medical, dental, and vision expenses such as co-
pays. You can request that each party pays a percentage of any uncovered medical expenses or
that you each pay in proportion to your respective incomes.
All reasonable uncovered and/or uninsured medical, dental, vision care, prescription and other
health care charges for the minor child(ren), including co-payments shall be allocated as follows:
Petitioner and Respondent are to pay in proportion to their respective incomes according to
the child support calculator.
Case Number: S1100DO2
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OR
Petitioner
to pay %
Respondent
to pay %
8.
Tax Exemptions
INSTRUCTIONS:
The child support calculator provides guidelines regarding who should
claim the child(ren) as tax exemptions each year. If you wish to deviate from these guidelines
check the “other” box and write in what you are requesting.
The parents shall claim the child(ren) as income tax dependency exemptions on federal and state
tax returns as follows:
Petitioner
OR
Respondent will claim the children every year.
Petitioner
OR
Respondent will claim the children every odd year.
Petitioner
OR
Respondent will claim the children every even year.
Other:
The parent required to pay child support is only entitled to claim the child(ren) as an income tax
dependency exemption if that parent has paid all of the child support due and owing for theyear.
9.
Spousal Maintenance
INSTRUCTIONS:
Earlier in the Petition you told the court whether or not one of the parties
should receive spousal maintenance from the other party. Here, you tell the court how much per
month and for how long that spouse should receive spousal maintenance or if neither party
should pay spousal maintenance to the other party.
Neither party to pay spousal maintenance to the other party.
OR
Petitioner shall receive spousal maintenance from Respondent in the amount of $
per month and the payments to continue until the receiving party is remarried or
deceased.
OR
Petitioner shall receive spousal maintenance from Respondent in the amount of $
per month and the
payments to continue until the receiving party is remarried or deceased or
for months, whichever
comes first.
OR
Respondent shall receive spousal maintenance from Petitioner in the amount of $
per month and
the payments to continue until the receiving party is remarried or deceased.
Case Number: S1100DO2
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OR
Respondent shall receive spousal maintenance from Petitioner in the amount of $
per month and the payments to continue until the receiving party is remarried or deceased or
for months,
whichever comes first.
INSTRUCTIONS:
Do you want either the other party or yourself to be able to modify
spousal maintenance in the future? If so, check the first box. If not, check the second box.
Spousal maintenance shall be modified in accordance with Arizona law.
Spousal maintenance shall NOT be modifiable for any reason.
10.
Debt
INSTRUCTIONS:
You must identify all of your debt as either community debt or separate
debt.
Community debts
are debts that you or the other party incurred during the marriage.
Separate debts
are debts that you or the other party incurred before the marriage.
a.
Community Debt:
Community debts are debts incurred by either party during the marriage.
You should see a lawyer about how to divide secured and unsecured debts. Community debts
shall be divided as follows:
INSTRUCTIONS:
Check this box if you do not have any community debt.
My spouse and I do not have any community debts.
INSTRUCTIONS:
Check this box if you have community debt. List all community debts, the
total owed, and the amount OR percentage to be paid by each party. If you need more space
attach an additional sheet of paper and check the box “The list continues on attached page.”
My spouse and I have community debts which shall be divided as follows:
Creditor Name
Amount Owed
Amount or
Percent to be paid
by Petitioner
Amount or
Percent to be
paid
by Respondent
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The list continues on attached page.
Petitioner is ordered to pay all debts unknown to Respondent.
Respondent is ordered to pay all debts unknown to Petitioner.
Each party is ordered to pay his or her debts incurred since (date) .
Any debts or obligations incurred by either party before the date of separation, that are not
identified in the list above or attached, shall be paid by the party who incurred the debt or
obligation and that party shall indemnify and hold the other party harmless from such debts.
b.
Separate Debt:
Separate debts are debts incurred before the marriage. Check ONLY one
of the three boxes. If you check the last box, list your separate debts, the total owed, and
the amount or percentage to be paid by each party. Separate debts shall be divided as
follows:
Neither my spouse nor I have any separate debt.
My spouse and/or I have separate debts and Husband must pay his separate debt and
Wife must pay her separate debt.
My spouse and/or I have separate debts and they shall be divided as follows:
Creditor Name
Amount Owed
Amount or
Percent to be paid
by Petitioner
Amount or
Percent to be
paid
by Respondent
11.
Property
IMPORTANT
: If there is a piece of property with a debt attached such as a car with a
loan, you must list the property under “Property” and the debt under “Debt”.
INSTRUCTIONS:
You must identify all of your property as either community property or
separate property.
Community property
is property that you acquired during the marriage, but
was not gifted to either you or the other party and that was not inherited.
Separate property
is
property that you acquired before the marriage, property that was gifted to either you or the
other party, or that was inherited.
a.
Community Property:
Community Property is property that was acquired during the
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marriage, which was not gifted to one party or inherited. Community Property shall be
divided as follows:
My spouse and I did not acquire any community property during the marriage.
OR
My spouse and I acquired community property during the marriage and it should be
divided as follows:
Include vehicles on this list.
Description of Property Awarded to Awarded to Value
Petitioner Respondent
$
$
$
$
$
$
$
$
$
$
b.
Separate Property:
Separate property is property acquired before the marriage, property
that was gifted to one party, or that was inherited. Separate Property to be divided as
follows:
My spouse and I do not have separate property.
My spouse and/or I have separate property and each party shall be awarded his or her
own separate property.
My spouse and/or I have separate property, which shall be divided as follows:
Description of Property Awarded to Awarded to Value
Petitioner Respondent
$
$
$
$
$
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$
$
$
$
$
c.
Real Property:
Real property is the house and land you own. You can ask the court to
give you the home, to give the home to the other party, or to sell the home and divide any
loss or proceeds. Write the complete address of the property under “real property located
at”. Most property has a legal description such as “LOT 77, PINE TREE ACRES,
according to Book 111 of Maps” which appears on your deed papers. You should use this
description. A cemetery plot is considered real property.
My spouse and I do not have real property.
My spouse and I have real property located at:
valued at approximately $ . The legal description of the property is (this
information is needed prior to an order
being entered regarding real property):
The real property shall be sold and any loss or proceeds divided with Petitioner
being awarded
%
and Respondent being awarded %.
The real property shall be awarded to Petitioner.
The real property shall be awarded to Respondent.
The party being awarded the real property will refinance the real property solely
in his or her name on or before (insert date). If unsuccessful, the
real property will be
INSTRUCTIONS:
Complete only if there is a second property.
My spouse and I do not have additional real property.
My spouse and I have additional real property located at:
valued at approximately $ . The legal description of the property is (this
information is needed prior to an order
being entered regarding real property):
The real property shall be sold and any loss or proceeds divided with Petitioner
being awarded
%
and Respondent being awarded %.
The real property shall be awarded to Petitioner.
The real property shall be awarded to Respondent.
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The party being awarded the real property will refinance the real property solely
in his or her name on or before (insert date). If unsuccessful, the
real property will be
d.
Retirement:
WARNING:
You should see a lawyer about your retirement accounts. If you do not see
a lawyer regarding these assets, you risk losing any interest you have in these plans and/or
benefits. There are certain documents the plan administrator must have. It is
recommended that you consult with a lawyer to help you prepare these documents.
INSTRUCTIONS:
A retirement account is considered property. Any part of the
retirement that grew during the marriage is community property. Any part of the
retirement that existed before the marriage, is separate property. You do not need to list
the retirement under “Property” if you list it here.
IMPORTANT:
If you want to divide the retirement account(s) you must see an attorney
about a document called a Qualified Domestic Relations Order (QDRO) or a Court Order
Acceptable for Processing (COAP). A QDRO or a COAP is a very specialized legal
document. It is recommended that you seek professional assistance to prepare the QDRO
or COAP. Do not have this done until a judge signs your Decree.
Neither party has a retirement account.
Each party
waives and gives
up his/her interest in any and all retirement benefits,
pension plans, or other deferred compensation of the other party.
Divide retirement accounts as follows:
12.
Taxes
INSTRUCTIONS:
This question is asking how you and the other party have filed taxes during
the time you were married.
a.
For
previous
calendar years, pursuant to IRS rules and regulations, the parties have filed
or will file:
INSTRUCTIONS:
If you and the other party ever filed jointly, check this box and list
the tax years you filed jointly.
Joint federal and state income tax returns for (years) and hold each other
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harmless from half
of all income taxes and costs, if any, and each party will share equally
in tax refunds, if any.
INSTRUCTIONS:
If you and the other party ever filed separately, check this box and
list the tax years you filed separately.
Separate federal and state income tax returns for (years) .
Other:
This calendar year and continuing thereafter, each party will file separate federal and
state income tax returns.
Each party shall give the other party all necessary documentation to file all tax returns,
unless that information is protected.
Other information and request(s) regarding taxes:
13.
Other Orders:
INSTRUCTIONS:
Use this space to add any more Orders the court is making.
FINAL APPEALABLE ORDER: Pursuant to Arizona Rules of Family Law Procedure,
Rule 81, this final judgment/decree is settled, approved and signed by the court and shall
be entered by the clerk.
SIGNATURES
DONE IN OPEN COURT:
JUDGE OR COURT COMMISSIONER:
If this Decree was issued as a “Default,”
and
the Petitioner served the papers to begin this
case by any means other than by publication, a copy of this Decree shall be mailed or delivered
to the Respondent within 24 hours of the court hearing as follows:
Respondent’s Name:
Mailing Address:
Case Number: S1100DO2
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City, State, Zip Code:
Email Address:
By Petitioner:
Date:
Petitioner’s Signature:
INSTRUCTIONS:
This page only applies if both parties are willing to sign this decree.
By signing this Consent Decree and subscribing and swearing to same (or affirming to same)
before a Notary Public, both parties affirm that the information is true and correct, including the
following:
1.
RIGHT TO TRIAL IS WAIVED.
I understand that by signing this Consent Decree,
I am waiving my right to trial before a judge.
2.
NO DURESS OR COERCION. COMPLETE AGREEMENT.
I am not under
any force, threats, duress, coercion, or undue influence from anyone, including the
other party, to sign this Consent Decree. This Decree with attachments, if any that I
have signed is our full agreement. I have not agreed to something different from what
is stated in writing in the Decree.
3.
LEGAL ADVICE.
I understand that even if I am representing myself without an
attorney, I have the right to be represented by an attorney. I have the right to call an
attorney and get legal advice before I sign this Consent Decree.
SIGNATURES OF THE PARTIES OR THEIR ATTORNEYS
APPROVED BY:
Date
Signature
State of Arizona )
)
County of )
(Arizona County)
Subscribed and sworn (or affirmed) before me this
day of
,
20
by
(Day) (Month) (Year)
(Name of Signer)
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(seal)
(Affix notary seal here)
Notary Public (Notary’s Signature)
Date
Signature
State of Arizona )
)
County of )
(Arizona County)
Subscribed and sworn (or affirmed) before me this
day of
,
20
by
(Day) (Month) (Year)
(Name of Signer)
(seal)
(Affix notary seal here)
Notary Public (Notary’s Signature)
If either party is represented by an attorney, the attorney must sign:
Petitioner’s Attorney: Date:
Respondent’s Attorney: Date:
Case Number: S1100DO2
Arizona Supreme Court Page 1 of 9 DRS81F-120816
Revised March 2016
Person Filing:
Address (if not protected):
City, State, Zip Code:
Telephone Numbers:
Email Address:
ATLAS Number:
Representing [ ] Self or [ ] Lawyer for
Lawyer Bar Number:
SUPERIOR COURT OF ARIZONA
IN COUNTY
Case Number: S1100DO2
Petitioner
CHILD SUPPORT ORDER
Respondent
THE COURT FINDS that:
1. , Petitioner, and ,
Respondent, owe a duty to support the following child(ren):
Name Date of Birth
2. CHILD SUPPORT GUIDELINES: The required financial factors and any discretionary
adjustments pursuant to the Arizona Child Support Guidelines are as set forth in the Parent’s
Worksheet for Child Support, attached and incorporated herein by reference.
3. CHILD SUPPORT:
[ ] [ ] Petitioner [ ] Respondent is obligated to pay child support to [ ] Petitioner
[ ] Respondent in the amount of $ per month pursuant to the Arizona Child
Support Guidelines without deviation.
FOR CLERK USE
ONLY
Case Number:
Arizona Supreme Court Page 2 of 9 DRS81F-112916
Revised March 2016
[ ] [ ] Petitioner [ ] Respondent is obligated to pay child support to [ ] Petitioner
[ ] Respondent in the amount of $ per month pursuant to the Arizona Child
Support Guidelines without deviation. This amount is an appropriate amount to award for
child support in this case except that the Court finds it more appropriate and just to make
a rounding adjustment to the exact guideline amount for ease of calculation to $
per month.
[ ] [ ] Petitioner [ ] Respondent is obligated to pay child support to [ ] Petitioner
[ ] Respondent in the amount of $ per month pursuant to the Arizona Child
Support Guidelines. Application of the child support guidelines in this case is
inappropriate or unjust. The Court has considered the best interests of the child in
determining that a deviation is appropriate.
After deviation the child support order is $ per month.
[ ] [ ] Petitioner [ ] Respondent is obligated to pay child support to [ ] Petitioner
[ ] Respondent in the amount of $ per month pursuant to the Arizona Child
Support Guidelines. Application of the child support guidelines in this case is
inappropriate or unjust. The Court has considered the best interests of the child in
determining that a deviation is appropriate.
After deviation the child support order is $ per month. Further, the parties have
entered into a written agreement or their agreement is on the record and is free of duress
and coercion with knowledge of the amount of child support that would have been
ordered under the guidelines but for the agreement.
Reason(s) for deviation:
4. SUPPORT ARREARS:
[ ] [ ] Petitioner [ ] Respondent owes child support arrearages to [ ] Petitioner
[ ] Respondent in the total amount of $ for the time period of
through plus
accrued interest on prior child support arrearages due of $ calculated through
the date of .
Case Number:
Arizona Supreme Court Page 3 of 9 DRS81F-112916
Revised March 2016
[ ] The court finds no child support arrearages due and owing.
[ ] No evidence was presented in support of child support arrearages.
5. PAST SUPPORT:
[ ] It is appropriate to award [ ] Petitioner [ ] Respondent an additional judgment for past
support in the amount of $ for the period between the filing of this current
petition and the date current child support is ordered to begin.
[ ] Temporary support or voluntary / direct support payments in the amount of
$ were paid during the period above; therefore the past support is
adjusted to $ .
[ ] It is appropriate to award [ ] Petitioner [ ] Respondent an additional judgment in the
amount of $ for past support owed from the date of separation, but not more
than three years before the date of filing the current petition.
[ ] Temporary support or voluntary / direct support payments in the amount of
$ were paid during the period above; therefore the past support is
adjusted to $ .
[ ] The court finds no past support amount due and owing.
[ ] No evidence was presented in support of past child support.
[ ] The court finds no temporary support or voluntary / direct support payments were
paid.
[ ] No evidence was presented in support temporary support or voluntary / direct support
payments.
Case Number:
Arizona Supreme Court Page 4 of 9 DRS81F-112916
Revised March 2016
IT IS ORDERED that:
A. CHILD SUPPORT:
[ ] [ ] Petitioner [ ] Respondent shall pay child support to [ ] Petitioner [ ] Respondent
in the sum of $ per month payable by income withholding order on the first day of
each month commencing .
B. SUPPORT ARREARAGES JUDGMENT:
[ ] [ ] Petitioner [ ] Respondent is granted judgment against [ ] Petitioner [ ]
Respondent in the sum of $ as and for child support arrearages for the period of
through the date of
together with interest on said sum at the legal rate of 10% per annum until paid in full
plus additional accrued interest on prior child support judgments of $
calculated through the date of .
[ ] Petitioner [ ] Respondent shall pay, in addition to [ ] his [ ] her current support
payment, the sum of $ per month toward this judgment, payable on the first day
of each month commencing until paid in full.
[ ] No judgment for child support arrearages is entered.
C. PAST SUPPORT JUDGMENT:
[ ] [ ] Petitioner [ ] Respondent is granted a past support judgment against [ ] Petitioner
[ ] Respondent in the additional amount of $ . [ ] Petitioner
[ ] Respondent shall pay the additional amount of $ per month toward
this judgment, payable on the first day of each month commencing
until paid in full.
[ ] No judgment for past support is entered.
D. PAYMENTS AND CLEARINGHOUSE: All payments, plus the statutory handling fee, shall
be made through the Support Payment Clearinghouse pursuant to an Order of Assignment or
Income Withholding Order signed this date. Any time the full amount of support ordered is not
withheld, the obligor (the party being ordered to pay) remains responsible for the full monthly
amount ordered. Payments not made directly through the Support Payment Clearinghouse shall
Case Number:
Arizona Supreme Court Page 5 of 9 DRS81F-112916
Revised March 2016
be considered gifts unless otherwise ordered. All payments shall be made payable to and mailed
directly to:
Support Payment Clearinghouse
PO Box 52107
Phoenix, AZ 85072-2107
Payments must include the [ ] Petitioner’s [ ] Respondent’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 the 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.
E. TOTAL MONTHLY PAYMENTS: [ ] Petitioner [ ] Respondent shall make total monthly
payments to [ ] Petitioner [ ] Respondent of $ per month payable on the first day
of each month commencing as follows:
Monthly Payments:
Current child support payment as ordered above: $
Current spousal maintenance payment: $
Support arrearage payment: $
Clearinghouse handling fee: $ 5.00
Total monthly payment: $
F. MEDICAL, DENTAL, AND VISION INSURANCE FOR THE MINOR CHILD(REN)
(A.R.S. § 25-320(J)):
[ ] [ ] Petitioner [ ] Respondent shall be individually responsible for providing medical
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.
Case Number:
Arizona Supreme Court Page 6 of 9 DRS81F-112916
Revised March 2016
[ ] [ ] Petitioner [ ] Respondent 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 reasonable cost, as neither party currently has the ability to obtain such
medical insurance.
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).
G. NON-COVERED MEDICAL EXPENSES: [ ] Petitioner is ordered to pay % and
Respondent 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. The party
responsible for payment or reimbursement must pay their share, as ordered by the court, or make
acceptable payment arrangements with the provider or person entitled to reimbursement within
45 days after receipt of the request.
H. TRAVEL EXPENSES: The costs of travel related to parenting time over 100 miles away shall
be shared as follows: Petitioner % Respondent %
I. OTHER FINDINGS AND ORDERS:
J. INFORMATION EXCHANGE: The parties shall exchange financial information such as
copies of tax returns, financial affidavits, and earnings statements every twenty-four months. At
the time the parties exchange financial information, they shall also exchange residential
addresses and the names and addresses of their employers unless the court has ordered otherwise.
Case Number:
Arizona Supreme Court Page 7 of 9 DRS81F-112916
Revised March 2016
K. TAX EXEMPTIONS. The Court allocates tax exemptions for the dependent children as
follows:
Child’s Name Date of Birth Party Entitled For
(Month, Day, Year) to Deduction Calendar
Year
[ ] Petitioner [ ] Respondent
[ ] Petitioner [ ] Respondent
[ ] Petitioner [ ] Respondent
[ ] Petitioner [ ] Respondent
[ ] Petitioner [ ] Respondent
[ ] Petitioner [ ] Respondent
For any years following those listed above while the Child Support Order remains in effect, the
parties shall repeat the above pattern of claiming deductions for each child.
[ ] [ ] Petitioner [ ] Respondent may claim the allocated tax exemptions only if all support
and arrears ordered for the year have been paid by December 31 of that year. An Internal
Revenue Service form 8332 may need to be signed and filed with a party’s income tax
return. See IRS Form 8332 for more detailed information. https://www.irs.gov/pub/irs-
pdf/f8332.pdf
[ ] [ ] Petitioner [ ] Respondent may unconditionally claim the tax exemption allocated to
[ ] Petitioner [ ] Respondent for income tax purposes. An Internal Revenue Service
Form 8332 may need to be signed and filed with a party’s income tax return. See IRS
Form 8332 for more detailed information. https://www.irs.gov/pub/irs-pdf/f8332.pdf
L. MODIFICATION: If this is a modification of child support, all other prior orders of this Court
not modified remain in full force and effect.
Even though the court’s judgment contains orders regarding medical insurance and the
allocation of the right to claim the child as a dependent for the purposes of federal taxes, these
orders are not binding on the IRS. Under the Affordable Care Act, the party who claims a
child as a dependent on a federal tax return has the obligation to ensure that the child is
covered by medical insurance and may be penalized by the IRS for failing to do so. This
penalty may be imposed even if it is the other party’s responsibility to carry medical insurance
on the child under the Decree of Dissolution of Marriage.
Case Number:
Arizona Supreme Court Page 8 of 9 DRS81F-112916
Revised March 2016
M. EMANCIPATION: A child is emancipated:
On the child’s 18th birthday, however if a child is still attending high school or a certified
high school equivalency program, support will continue until graduation or the child
reaches 19 years of age.
On the date of the child’s marriage.
When the child is adopted.
When the child dies.
Date Judicial Officer
Typed or Printed Name of Judicial Officer
Case Number:
Arizona Supreme Court Page 9 of 9 DRS81F-112916
Revised March 2016
STIPULATION
(24) SIGNATURE BY PETITIONER AND RESPONDENT:
By signing this document, we state to the Court, under penalty of perjury, that we have read and agree to
this Order and that all the information contained in it is true, correct and complete to the best of our
knowledge and belief.
Date Petitioner’s Signature
Date Respondent’s Signature
If either party is represented by a lawyer, the lawyer(s) must sign below:
Date Petitioner’s Lawyer
Date Respondent’s Lawyer
_________________________________________________________________________________________________________
INCOME WITHHOLDING FOR SUPPORTInstructions OMB 0970-0154 Expiration Date: 08/31/2020 Page 1 of 7
INCOME WITHHOLDING FOR SUPPORT - Instructions
The Income Withholding for Support (IWO) is the OMB-approved form used for income withholding in:
tribal, intrastate, and interstate cases enforced under Title IV-D of the Social Security Act
all child support orders initially issued in the state on or after January 1, 1994, and
all child support orders initially issued (or modified) in the state before January 1, 1994 if
arrearages occur.
This form is the standard format prescribed by the Secretary in accordance with section 466(b)(6)(a)(ii) of
the Social Security Act. Except as noted, the following information is required and must be
included.
Please note:
For the purpose of this IWO form and these instructions, “state” is defined as a state or territory.
Dos and don’ts on using this form are found at
www.acf.hhs.gov/css/resource/using-the-income-
withholding-for-support-form-dos-and-donts.
COMPLETED BY SENDER:
1a. In
come Withholding Order/Notice for Support (IWO). Check the box if this is an initial IWO.
1b. Amended IWO. Check the box to indicate that this form amends a previous IWO. Any changes
to an IWO must be done through an amended IWO.
1c. One-Time Order/Notice For Lump Sum Payment. Check the box when this IWO is to attach a
one-time collection of a lump sum payment after receiving notification from an employer/income
withholder or other source. When this box is checked, enter the amount in field 14, Lump Sum
Payment, in the Amounts to Withhold section. Additional IWOs must be issued to collect
subsequent lump sum payments.
1d. Termination of IWO. Check the box to stop income withholding on a child support order.
Complete all applicable identifying information to aid the employer/income withholder in
terminating the correct IWO.
1e. Date. Date this form is completed and/or signed.
1f. Child Support Enforcement (CSE) Agency, Court, Attorney, Private Individual/Entity
(Check One). Check the appropriate box to indicate which entity is sending the IWO. If this IWO
is not completed by a state or tribal CSE agency, the sender should contact the CSE agency
(see
www.acf.hhs.gov/programs/css/resource/state-income-withholding-contacts-and-program-
requirements) to determine if the CSE agency needs a copy of this form to facilitate payment
processing.
NOTE TO EMPLOYER/INCOME WITHHOLDER:
Thi
s IWO must be regular on its face. The IWO must be rejected and returned to sender under the
following circumstances:
IWO instructs the employer/income withholder to send a payment to an entity other than a state
disbursement unit (for example, payable to the custodial party, court, or attorney). Each state is
required to operate a state disbursement unit (SDU), which is a centralized facility for collecti
on
and
disbursement of child support payments. Exception: If this IWO is issued by a court,
attorney, or private individual/entity and the initial child support order was entered before January
1, 1994 or the order was issued by a tribal CSE agency, the employer/income withholder must
follow the payment instructions on the form.
Form does not contain all information necessary for the employer to comply with the withholding.
Form is altered or contains invalid information.
_________________________________________________________________________________________________________
INCOME WITHHOLDING FOR SUPPORTInstructions Page 2 of 7
Amount to withhold is not a dollar amount.
Sender has not used the OMB-approved form for the IWO.
A copy of the underlying order is required and not included.
If you receive this document from an attorney or private individual/entity, a copy of the underlying support
order containing a provision authorizing income withholding must be attached.
COMPLETED BY SENDER:
1g.
State/Tribe/Territory. Name of state or tribe sending this form. This must be a governmental
entity of the state or a tribal organization authorized by a tribal government to operate a CSE
program. If you are a tribe submitting this form on behalf of another tribe, complete field 1i.
1h
. Remittance ID (include w/payment). Identifier that employers/income withholders must include
when sending payments for this IWO. The Remittance ID is entered as the case identifier on the
electronic funds transfer/electronic data interchange (EFT/EDI) record.
NOTE TO EMPLOYER/INCOME WITHHOLDER:
The employer/income withholder must use the Remittance ID when remitting payments so the SDU or
tribe can identify and apply the payment correctly. The Remittance ID is entered as the case identifier on
the EFT/EDI record.
COMPLETED BY SENDER:
1i. C
ity/County/Dist./Tribe. Optional field for the name of the city, county, or district sending this
form. If entered, this must be a government entity of the state or the name of the tribe authorized
by a tribal government to operate a CSE program for which this form is being sent. If a tribe is
submitting this form on behalf of another tribe, enter the name of that tribe.
1j. Order ID. Unique identifier associated with a specific child support obligation. It could be a court
case number, docket number, or other identifier designated by the sender.
1k. Private Individual/Entity. Name of the private individual/entity or non-IV-D tribal CSE
organization sending this form.
1l. Case ID. Unique identifier assigned to a state or tribal CSE case. In a state IV-D case as defined
at 45 Code of Federal Regulations (CFR) 305.1, this is the identifier reported to the Federal Case
Registry (FCR). One IWO must be issued for each IV-D case and must use the unique CSE
Agency Case ID. For tribes, this would be either the FCR identifier or other applicable identifier.
Fields 2 and 3 refer to the employee/obligor’s employer/income withholder and specific case information.
2a. Employer/Income Withholder's Name. Name of employer or income withholder.
2b. Employer/Income Withholder's Address. Employer/income withholder's mailing address
including street/PO box, city, state, and zip code. (This may differ from the employee/obligor’s
work site.) If the employer/income withholder is a federal government agency, the IWO should be
sent to the address listed under Federal Agency Income Withholding Contacts and Program
Information at
www.acf.hhs.gov/css/resource/federal-agency-iwo-and-medical-contact-
information.
2c. E
mployer/Income Withholder's FEIN. Employer/income withholder's nine-digit Federal
Employer Identification Number (if available).
_________________________________________________________________________________________________________
INCOME WITHHOLDING FOR SUPPORTInstructions Page 3 of 7
3a. Employee/Obligor’s Name. Employee/obligor’s last name and first name. A middle name is
optional.
3b. Employee/Obligor’s Social Security Number. Employee/obligor’s Social Security number or
other taxpayer identification number.
3c. Employee/Obligor’s Date of Birth. Employee/obligor’s date of birth is optional.
3d. Custodial Party/Obligee’s Name. Custodial party/obligee’s last name and first name. A middle
name is optional. Enter one custodial party/obligee’s name on each IWO form. Multiple
custodial parties/obligees are not to be entered on a single IWO. Issue one IWO per state IV-D
case as defined at 45 CFR 305.1.
3e. Child(ren)’s Name(s). Child(ren)’s last name(s) and first name(s). A middle name(s) is
optional. (Note: If there are more than six children for this IWO, list additional children’s names
and birth dates in the Supplemental Information section). Enter the child(ren) associated with
the custodial party/obligee and employee/obligor only. Child(ren) of multiple custodial
parties/obligees is not to be entered on an IWO.
3f. Child(ren)’s Birth Date(s). Date of birth for each child named.
3g. Blank box. Space for court stamps, bar codes, or other information.
ORDER INFORMATIONField 4 identifies which state or tribe issued the order. Fields 5 through 12
identify the dollar amounts for specific kinds of support (taken directly from the support order) and the
total amount to withhold for specific time periods.
4. State/Tribe. Name of the state or tribe that issued the support order.
5a-b. C
urr
ent Child Support. Dollar amount to be withheld per the time period (for example, week,
month) specified in the underlying support order.
6a-b. Past-due Child Support. Dollar amount to be withheld per the time period (for example, week,
month) specified in the underlying support order.
6c. Arrears Greater Than 12 Weeks? The appropriate box (Yes/No) must be checked indicating
whether arrears are greater than 12 weeks.
7a-b. Current Cash Medical Support. Dollar amount to be withheld per the time period (for example,
week, month) specified in the underlying support order.
8a-b. Past-due Cash Medical Support. Dollar amount to be withheld per the time period (for
example, week, month) specified in the underlying support order.
9a-b. Current Spousal Support. (Alimony) Dollar amount to be withheld per the time period (for
example, week, month) specified in the underlying support order.
10a-b. Past-du
e Spousal Support. (Alimony) Dollar amount to be withheld per the time period (for
example, week, month) specified in the underlying order.
11a-c. Other. Miscellaneous obligations dollar amount to be withheld per the time period (for example,
week, month) specified in the underlying order. Must specify a description of the obligation (for
example, court fees).
12a-b. Total Amount to Withhold. The total amount of the deductions per the corresponding time
period. Fields 5a, 6a, 7a, 8a, 9a, 10a, and 11a should total the amount in 12a.
_________________________________________________________________________________________________________
INCOME WITHHOLDING FOR SUPPORTInstructions Page 4 of 7
NOTE TO EMPLOYER/INCOME WITHHOLDER:
An acc
eptable method of determining the amount to be paid on a weekly or biweekly basis is to multiply
the monthly amount due by 12 and divide that result by the number of pay periods in a year. Additional
information about this topic is available in Action Transmittal 16-04
, Correctly Withholding Child Support
from Weekly and Biweekly Pay Cycles (https://www.acf.hhs.gov/css/resource/correctly-withholding-child-
support-from-weekly-and-biweekly-pay-cycles).
COMPLETED BY SENDER:
AMOUNTS TO WITHHOLD - Fields 13a through 13d specify the dollar amount to be withheld for this
IWO if the employer/income withholder’s pay cycle does not correspond with field 12b.
13a. Per Weekly Pay Period. Total amount an employer/income withholder should withhold if the
employee/obligor is paid weekly.
13b. Per Semimonthly Pay Period. Total amount an employer/income withholder should withhold if
the employee/obligor is paid twice a month.
13c. Per Biweekly Pay Period. Total amount an employer/income withholder should withhold if the
employee/obligor is paid every two weeks.
13d. Per Monthly Pay Period. Total amount an employer/income withholder should withhold if the
employee/obligor is paid once a month.
14. Lump Sum Payment. Dollar amount withheld when the IWO is used to attach a lump sum
payment. This field should be used when field 1c is checked.
15
. Document Tracking ID. Optional unique identifier for this form assigned by the sender.
Please Note: Employer’s Name, FEIN, Employee/Obligor’s Name and SSN, Case ID, and Order ID must
appear in the header on page two and subsequent pages.
REMITTANCE INFORMATION - Pa
yments are forwarded to the SDU in each state, unless the initial child
support order was entered by a state before January 1, 1994 and never modified, accrued arrears, or was
enforced by a child support agency or by a tribal CSE agency. If the order was issued by a tribal CSE
agency, the employer/income withholder must follow the remittance instructions on the form.
16. State/Tribe. Name of the state or tribe sending this document.
17. Days. Number of days after the effective date noted in field 18 in which withholding must begi
n
according to the state or tribal laws/procedures for the employee/obligor’s principal place of
employment.
18. Date. Effective date of this IWO.
19. Business Days. Number of business days within which an employer/income withholder must
remit amounts withheld pursuant to the state or tribal laws/procedures of the principal place of
employment.
20. Percentage of Disposable Income. The percentage of disposable income that may be withhel
d
from the employee/obligor’s paycheck. It is the sender’s responsibility to determine the
percentage an employer/income withholder is required to withhold.
_________________________________________________________________________________________________________
INCOME WITHHOLDING FOR SUPPORTInstructions Page 5 of 7
NOTE TO EMPLOYER/INCOME WITHHOLDER:
The employer/income withholder may not withhold more than the lesser of: 1) the amounts allowed by
the Federal Consumer Credit Protection Act [15 USC §1673(b)]; or 2) the amounts allowed by the
jurisdiction of the employee/obligor’s principal place of employment (i.e., the amounts allowed by state
law if the employee/obligor’s principal place of employment is in a state; or the amounts allowed by tribal
law if the employee/obligor’s principal place of employment is under tribal jurisdiction). State-specific
withholding limitations, time requirements, and any allowable employer fees are available at
www.acf.hhs.gov/css/resource/state-income-withholding-contacts-and-program-requirements
. For tribe-
specific contacts, payment addresses, and withholding limitations, please contact the tribe at
www.acf.hhs.gov/sites/default/files/programs/css/tribal_agency_contacts_printable_pdf.pdf or
https://www.bia.gov/tribalmap/DataDotGovSamples/tld_map.html.
A federal government agency may withhold from a variety of incomes and forms of payment, including
voluntary separation incentive payments (buy-out payments), incentive pay, and cash awards. For a
more complete list, see 5 CFR 581.103.
COMPLETED BY SENDER:
21. Stat
e/Tribe. Name of the state or tribe sending this document.
22. Locator Code. Geographic Locator Codes are standard codes for states, counties, and cities
issued by the National Institute of Standards and Technology. These were formerly known as
Federal Information Processing Standards (FIPS) codes.
23. SDU/Tribal Order Payee. Name of SDU (or payee specified in the underlying tribal support
order) to which payments must be sent.
24. SDU/Tribal Payee Address. Address of the SDU (or payee specified in the underlying triba
l
support order) to which payments must be sent.
COMPLETED BY EMPLOYER/INCOME WITHHOLDER:
25
. Return to Sender Checkbox. The employer/income withholder should check this box and retur
n
the IWO to the sender if this IWO is not payable to an SDU or Tribal Payee or this IWO is not
regular on its face as indicated on page 1 of these instructions.
COMPLETED BY SENDER IF REQUIRED BY STATE OR TRIBAL LAW:
26. Signature of Judge/Issuing Official. Signature of the official authorizing this IWO.
27. Print Name of Judge/Issuing Official. Name of the official authorizing this IWO.
28. Title of Judge/Issuing Official. Title of the official authorizing this IWO.
29. Date of Signature. Date the judge/issuing official signs this IWO.
30. Copy of IWO checkbox. Check this box for all intergovernmental IWOs. If checked, t
he
em
ployer/income withholder is required to provide a copy of the IWO to the employee/obligor.
ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS
The following fields refer to federal, state, or tribal laws that apply to issuing an IWO to an
employer/income withholder. State- or tribal-specific information may be included only in the fields below.
_________________________________________________________________________________________________________
INCOME WITHHOLDING FOR SUPPORTInstructions Page 6 of 7
COMPLETED BY SENDER:
31.
Liability. Additional information on the penalty and/or citation of the penalty for an
employer/income withholder who fails to comply with the IWO. The state or tribal law/procedures
of the employee/obligor’s principal place of employment govern the penalty.
32. Anti-discrimination. Additional information on the penalty and/or citation of the penalty for an
employer/income withholder who discharges, refuses to employ, or disciplines an
employee/obligor as a result of the IWO. The state or tribal law/procedures of the
employee/obligor’s principal place of employment govern the penalty.
33. Supplemental Information. Any state-specific information needed, such as maximum
withholding percentage for nonemployees/independent contractors, fees the employer/income
withholder may charge the obligor for income withholding, or children’s names and DOBs if there
are more than six children on this IWO. Additional information must be consistent with the
requirements of the form and the instructions.
COMPLETED BY EMPLOYER/INCOME WITHHOLDER:
NOTIFICATION OF EMPLOYMENT TERMINATION OR INCOME STATUS
The employer must complete this section when the employee/obligor’s employment is terminated, income
withholding ceases, or if the employee/obligor has never worked for the employer.
34a-b. Employment/Income Status Checkbox. Check the employment/income status of the
employee/obligor.
35. Termination Date. If applicable, date employee/obligor was terminated.
36. Last Known Telephone Number. Last known (home/cell/other) telephone number of the
employee/obligor.
37. Last Known Address. Last known home/mailing address of the employee/obligor.
38. Final Payment Date. Date employer sent final payment to SDU/Tribal Payee.
39. Final Payment Amount. Amount of final payment sent to SDU/Tribal Payee.
40. New Employer’s Name. Name of employee’s/obligor’s new employer (if known).
41. New Employer’s Address. Address of employee’s/obligor’s new employer (if known).
COMPLETED BY SENDER:
CONTACT INFORMATION
42. Issuer Name (Employer/Income Withholder Contact). Name of the contact person that the
employer/income withholder can call for information regarding this IWO.
43. Issuer Telephone Number. Telephone number of the contact person.
44. Issuer Fax Number. Optional fax number of the contact person.
45. Issuer Email/Website. Optional email or website of the contact person.
46. Issuer A
ddress (Termination/Income Status and Correspondence Address). Address to
_________________________________________________________________________________________________________
INCOME WITHHOLDING FOR SUPPORTInstructions Page 7 of 7
which the employer should return the Employment Termination or Income Status notice. It is also
the address that the employer should use to correspond with the issuing entity.
47. Issuer Name (Employee/Obligor Contact). Name of the contact person that th
e
em
ployee/obligor can call for information.
48. Issuer Telephone Number. Telephone number of the contact person.
49. Issuer Fax Number. Optional fax number of the contact person.
50. Issuer Email/Website. Optional email or website of the contact person.
Encryption Requirements:
When communicating the Income Withholding for Support (IWO) through electronic transmission, precautions must
be taken to ensure the security of the data. Child support agencies are encouraged to use the electronic applications
provided by the federal Office of Child Support Enforcement. Other electronic means, such as encrypted
attachments to emails, may be used if the encryption method is compliant with Federal Information Processing
Standard (FIPS) Publication 140-2 (FIPS PUB 140-2).
The Paperwork Reduction Act of 1995
This information collection and associated responses are conducted in accordance with 45 CFR 303.100 of the Child
Support Enforcement Program. This form is designed to provide uniformity and standardization. Public reporting
burden for this collection of information is estimated to average 5 minutes per response for Non-IV-D CPs; 2 minutes
per response for employers; 3 seconds for e-IWO employers, including the time for reviewing instructions, gathering
and maintaining the data needed, and reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless
it displays a currently valid OMB control number.
Income Withholding for Support (IWO) OMB 0970-0154 Expiration Date: 08/31/2020 Page 1 of 5
INCOME WITHHOLDING FOR SUPPORT
INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO)
AMENDED IWO
ONE-TIME ORDER/NOTICE FOR LUMP SUM PAYMENT
TERMINATION OF IWO Date:
Child Support Enforcement (CSE) Agency Court Attorney Private Individual/Entity (Check One)
NOTE: This IWO must be regular on its face. Under certain circumstances you must reject this IWO and return it to the
sender (see IWO instructions www.acf.hhs.gov/css/resource/income-withholding-for-support-instructions)
. If you receive this
document from someone other than a state or tribal CSE agency or a court, a copy of the underlying support order must be
attached.
State/Tribe/Territory Remittance ID (include w/payment)
City/County/Dist./Tribe Order ID
Private Individual/Entity Case ID
RE:
Employer/Income Withholder’s Name Employee/Obligor’s Name (Last, First, Middle)
Employer/Income Withholder’s Address Employee/Obligor’s Social Security Number
Employee/Obligor’s Date of Birth
Custodial Party/Obligee’s Name (Last, First, Middle)
Employer/Income Withholder’s FEIN
Child(ren)’s Name(s) (Last, First, Middle) Child(ren)’s Birth Date(s)
ORDER INFORMATION: This document is based on the support order from (State/Tribe).
You are required by law to deduct these amounts from the employee/obligor's income until further notice.
$ Per current child support
$ Per past-due child support - Arrears greater than 12 weeks? Yes No
$ Per current cash medical support
$ Per past-due cash medical support
$ Per current spousal support
$ Per past-due spousal support
$ Per other (must specify)
for a Total Amount to Withhold of $ per .
AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with the Order Information. If
your pay cycle does not match the ordered payment cycle, withhold one of the following amounts:
$ per weekly pay period $ per semimonthly pay period (twice a month)
$ per biweekly pay period (every two weeks) $ per monthly pay period
$ Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order.
Document Tracking ID
01/02/2019
Arizona
Arizona
Month
Month
Month
Month
Month
Month
5.00
Month
Clearinghouse Fee.
5.00
Month
1.15
2.50
2.31
5.00
Employer’s Name: Employer FEIN:
Employee/Obligor’s Name: SSN:
Case Identifier: Order Identifier:
Income Withholding for Support (IWO) Page 2 of 5
REMITTANCE INFORMATION: If the employee/obligor's principal place of employment is
(State/Tribe), you must begin withholding no later than the first pay period that occurs days after the date
of . Send payment within business days of the pay date. If you cannot withhold the full
amount of support for any or all orders for this employee/obligor, withhold of disposable income for all
orders. If the obligor is a non-employee, obtain withholding limits from Supplemental Information. If the employee/obligor's
principal place of employment is not (State/Tribe), obtain withholding limitations, time
requirements, and any allowable employer fees from the jurisdiction of the employee/obligor’s principal place of
employment. State-specific withholding limit information is available at
www.acf.hhs.gov/css/resource/state-income-
withholding-contacts-and-program-requirements. For tribe-specific contacts, payment addresses, and withholding
limitations, please contact the tribe at
www.acf.hhs.gov/sites/default/files/programs/css/tribal_agency_contacts_printable_pdf.pdf or
https://www.bia.gov/tribalmap/DataDotGovSamples/tld_map.html.
For electronic payment requirements and centralized payment collection and disbursement facility information [State
Disbursement Unit (SDU)], see www.acf.hhs.gov/css/employers/employer-responsibilities/payments
.
Include the Remittance ID with the payment and if necessary this locator code: .
Remit payment to (SDU/Tribal Order Payee)
at (SDU/Tribal Payee Address)
Return to Sender (Completed by Employer/Income Withholder). Payment must be directed to an SDU in
accordance with sections 466(b)(5) and (6) of the Social Security Act or Tribal Payee (see Payments to SDU below). If
payment is not directed
to an SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return
the IWO to the sender.
If Required by State or Tribal Law:
Signature of Judge/Issuing Official:
Print Name of Judge/Issuing Official:
Title of Judge/Issuing Official:
Date of Signature:
If the employee/obligor works in a state or for a tribe that is different from the state or tribe that issued this order, a copy of
this IWO must be provided to the employee/obligor.
If checked, the employer/income withholder must provide a copy of this form to the employee/obligor.
ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS
State-specific contact and withholding information can be found on the Federal Employer Services website located at
www.acf.hhs.gov/css/resource/state-income-withholding-contacts-and-program-requirements
.
Employers/income withholders may use OCSE’s Child Support Portal (https://ocsp.acf.hhs.gov/csp/) to provide
information about employees who are eligible to receive a lump sum payment, have terminated employment, and to
provide contacts, addresses, and other information about their company.
Priority: Withholding for support has priority over any other legal process under State law against the same income
(section 466(b)(7) of the Social Security Act). If a federal tax levy is in effect, please notify the sender.
Combining Payments: When remitting payments to an SDU or tribal CSE agency, you may combine withheld amounts
from more than one employee/obligor's income in a single payment. You must, however, separately identify each
employee/obligor's portion of the payment.
Payments To SDU: You must send child support payments payable by income withholding to the appropriate SDU or to a
tribal CSE agency. If this IWO instructs you to send a payment to an entity other than an SDU (e.g., payable to the
custodial party, court, or attorney), you must check the box above and return this notice to the sender. Exception: If this
IWO was sent by a court, attorney, or private individual/entity and the initial order was entered before January 1, 1994 or
the order was issued by a tribal CSE agency, you must follow the “Remit payment to” instructions on this form.
Arizona
fourteen (14)
receipt of this Order
two (2)
fifty percent (50%)
Arizona
Support Payment Clearinghouse
P.O. Box 52107, Phoenix, AZ 85072-2107
Employer’s Name: Employer FEIN:
Employee/Obligor’s Name: SSN:
Case Identifier: Order Identifier:
Income Withholding for Support (IWO) Page 3 of 5
Reporting the Pay Date: You must report the pay date when sending the payment. The pay date is the date on which the
amount was withheld from the employee/obligor's wages. You must comply with the law of the state (or tribal law if
applicable) of the employee/obligor's principal place of employment regarding time periods within which you must
implement the withholding and forward the support payments.
Multiple IWOs: If there is more than one IWO against this employee/obligor and you are unable to fully honor all IWOs
due to federal, state, or tribal withholding limits, you must honor all IWOs to the greatest extent possible, giving priority to
current support before payment of any past-due support. Follow the state or tribal law/procedure of the employee/obligor's
principal place of employment to determine the appropriate allocation method.
Lump Sum Payments: You may be required to notify a state or tribal CSE agency of upcoming lump sum payments to
this employee/obligor such as bonuses, commissions, or severance pay. Contact the sender to determine if you are
required to report and/or withhold lump sum payments.
Liability: If you have any doubts about the validity of this IWO, contact the sender. If you fail to withhold income from the
employee/obligor's income as the IWO directs, you are liable for both the accumulated amount you should have withheld
and any penalties set by state or tribal law/procedure.
Anti-discrimination: You are subject to a fine determined under state or tribal law for discharging an employee/obligor
from employment, refusing to employ, or taking disciplinary action against an employee/obligor because of this IWO.
Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer
Credit Protection Act (CCPA) [15 USC §1673(b)]; or 2) the amounts allowed by the law of the state of the employee/
obligor's principal place of employment, if the place of employment is in a state; or the tribal law of the employee/obligor’s
principal place of employment if the place of employment is under tribal jurisdiction. Disposable income is the net
income after mandatory deductions such as: state, federal, local taxes; Social Security taxes; statutory pension
contributions; and Medicare taxes. The federal limit is 50% of the disposable income if the obligor is supporting another
family and 60% of the disposable income if the obligor is not supporting another family. However, those limits increase
5% --to 55% and 65% --if the arrears are greater than 12 weeks. If permitted by the state or tribe, you may deduct a fee
for administrative costs. The combined support amount and fee may not exceed the limit indicated in this section.
Depending upon applicable state or tribal law, you may need to consider amounts paid for health care premiums in
determining disposable income and applying appropriate withholding limits.
A
rrears Greater Than 12 Weeks? If the Order Information section does not indicate that the arrears are greater than 12
weeks, then the employer should calculate the CCPA limit using the lower percentage.
Supplemental Information:
Employer’s Name: Employer FEIN:
Employee/Obligor’s Name: SSN:
Case Identifier: Order Identifier:
Income Withholding for Support (IWO) Page 4 of 5
NOTIFICATION OF EMPLOYMENT TERMINATION OR INCOME STATUS: If this employee/obligor never worked for
you or you are no longer withholding income for this employee/obligor, you must promptly notify the CSE agency and/or
the sender by returning this form to the address listed in the contact information below:
This person has never worked for this employer nor received periodic income.
This person no longer works for this employer nor receives periodic income.
Please provide the following information for the employee/obligor:
Termination date: Last known telephone number:
Last known address:
Final payment date to SDU/Tribal Payee: Final payment amount:
New employer's name:
New employer's address:
CONTACT INFORMATION:
To Employer/Income Withholder: If you have questions, contact (issuer name)
by telephone: , by fax: , by email or website: .
Send termination/income status notice and other correspondence to:
(issuer address).
To Employee/Obligor: If the employee/obligor has questions, contact (issuer name)
by telephone: , by fax: , by email or website: .
I
MPORTANT: The person completing this form is advised that the information may be shared with the employee/obligor.
E
ncryption Requirements:
When communicating this form through electronic transmission, precautions must be taken to ensure the security of the
data. Child support agencies are encouraged to use the electronic applications provided by the federal Office of Child
Support Enforcement. Other electronic means, such as encrypted attachments to emails, may be used if the encryption
method is compliant with Federal Information Processing Standard (FIPS) Publication 140-2 (FIPS PUB 140-2).
T
he Paperwork Reduction Act of 1995
This information collection and associated responses are conducted in accordance with 45 CFR 303.100 of the Child Support
Enforcement Program. This form is designed to provide uniformity and standardization. Public reporting for this collection of
information is estimated to average two to five minutes per response.
An agency may not conduct or sponsor, and a person
is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
Income Withholding for Support (IWO) Page 5 of 5
Income Withholding Order Information Page
This order is effective . All rules on page 2 under REMITTANCE INFORMATION apply
after the effective date.
Presumptive Termination Date:
This order is presumed to terminate on the presumptive termination date when the
youngest child who is subject to this order is expected to emancipate as defined in A.R.S. §§ 25-320
and 25-501 unless the order contains a payment on arrears. The presumptive termination date of this
order may be modified by the court upon changed circumstances.
Note to Employers/Other Withholders:
If the most recent Income Withholding Order in the case is for
current child support only, you should discontinue withholding
monies after the last pay period of the month of the presumptive
termination date above. If the Income Withholding Order
includes current child support and an arrearage payment, you
should continue withholding the entire amount listed on the
order
until further notice.
Page 1 of 11
DO_PP_COSCPinal_11.19.18
Use only most current version
Name of Person Filing:
Street Address:
City, State, Zip Code:
Telephone Number:
Email Address:
ATLAS Number (if applicable):
Representing Self (No Attorney) or Represented by Attorney
If Attorney, Bar Number:
SUPERIOR COURT OF ARIZONA
PINAL COUNTY
CASE NUMBER:
S1100DO2
Name of Petitioner
PARENTING PLAN FOR:
JOINT LEGAL DECISION-MAKING
OR
SOLE LEGAL DECISION-MAKING
TO PETITIONER
TO RESPONDENT
Name of Respondent
HONORABLE:
GENERAL INFORMATION
A. MINOR CHILDREN This Plan concerns the following children common to the parents:
Name Birth Date
Page 2 of 11
DO_PP_COSCPinal_11.19.18
Use only most current version
B. LEGAL DECISION-MAKING:
Select One.
SOLE LEGAL DECISION-MAKING
Sole legal decision-making should be granted to
Petitioner or
Respondent
JOINT LEGAL DECISION-MAKING
EDUCATIONAL DECISIONS: Each parent has the right to participate in school
conferences, events and activities, and the right to consult with teachers and other
school personnel. (Select one)
Petitioner Respondent will make final Education Decisions
appropriate under all circumstances after good faith consultations with the
other parent.
Both parents shall make Education Decisions together
The children will not be moved to a school located outside of the school
district where they are currently enrolled without written agreement by both
parties.
Both parents will sign this Parenting Plan and agree that the children will
attend the following private school:
Other (specify):
RELIGIOUS DECISIONS (Select one)
Petitioner Respondent will make final Religious Decisions
appropriate under all circumstances after good faith consultations with the
other parent.
Both parents shall make Religious Decisions together
Petitioner shall make Religious Decisions
Respondent shall make Religious Decisions
MEDICAL DECISIONS (Select one)
Petitioner Respondent will make final Medical Decisions
appropriate under all circumstances after good faith consultations with the
other parent.
Both parents shall make Medical Decisions together
Case Number: S1100DO2
Page 3 of 11
DO_PP_COSCPinal_11.19.18
Use only most current version
Petitioner shall make Medical Decisions
Respondent shall make Medical Decisions
PERSONAL CARE DECISIONS (Select one)
Petitioner Respondent will make final Personal Decisions
appropriate under all circumstances after good faith consultations with the
other parent.
Both parents shall make Personal Care Decisions together
Petitioner shall make Personal Care Decisions
Respondent shall make Personal Care Decisions
C. PARENTING TIME Write your detailed parenting plan below. Include specific times,
locations, and details regarding transportation. You will have the opportunity to request
supervised parenting time or no parenting time, later in this document.
1. Regular Parenting Time:
2. Summer Months:
Case Number: S1100DO2
Page 4 of 11
DO_PP_COSCPinal_11.19.18
Use only most current version
3. School Breaks Longer Than 4 Days:
4. Three Day Weekends:(for example, Labor Day, Columbus Day, Martin Luther King, Jr.
Day, Presidents' Day and Memorial Day)
The parents agree that whichever of them has the child(ren) for the weekend occurring
nearer in time to the holiday will spend time with the child(ren) for the holiday, OR
Explain your request:
5. Transportation: Write your procedure for exchanges of the child(ren) including location
and responsibility for transportation.
6. Holiday, Birthday and Special Occasion Schedule Use the table below or the blank
space to write your schedule.
Event Even Years Odd Years
New Year’s Eve Petitioner Respondent Petitioner Respondent
New Year’s Day Petitioner Respondent Petitioner Respondent
Easter Petitioner Respondent Petitioner Respondent
4
th
of July Petitioner Respondent Petitioner Respondent
Halloween Petitioner Respondent Petitioner Respondent
Veteran’s Day Petitioner Respondent Petitioner Respondent
Case Number: S1100DO2
Page 5 of 11
DO_PP_COSCPinal_11.19.18
Use only most current version
Thanksgiving Petitioner Respondent Petitioner Respondent
Christmas Eve Petitioner Respondent Petitioner Respondent
Christmas Day Petitioner Respondent Petitioner Respondent
Child(ren)’s Birthday Petitioner Respondent Petitioner Respondent
Mother’s Day Petitioner Respondent Petitioner Respondent
Father’s Day Petitioner Respondent Petitioner Respondent
Petitioner’s Birthday Petitioner Respondent Petitioner Respondent
Respondent’s Birthday Petitioner Respondent Petitioner Respondent
7. Telephone Contact with Children
Each parent may have telephone contact with the child(ren) during the child(ren)’s normal
waking hours, OR
Explain your request:
8. Travel with Child(ren) (all of the following are optional)
Each parent is entitled to consecutive days of vacation time per year with the
child(ren). Each parent will give the other parent days notice prior to the vacation.
Should either parent travel out of the area with the minor child(ren), each parent will keep
the other parent informed of travel plans, address(es), and telephone numbers at which that
parent and the minor child(ren) can be reached.
Neither parent shall travel with the minor child(ren) outside of Arizona for longer than
______ days without the prior written consent of the other parent or order of the court.
SUPERVISED PARENTING TIME
Supervised parenting time is in the best interest of the minor child(ren) because:
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Name of the agency or person who will supervise:
NO PARENTING TIME BETWEEN CHILD(REN) AND
PETITIONER
OR
RESPONDENT
No parenting time is in the best interest of the minor child(ren) because:
D. Medical and Dental Arrangements
Both parents have the right to authorize emergency medical treatment, if needed, and the
right to consult with physicians and other medical practitioners. Both parents agree to advise
the other parent with physicians and other medical practitioners. Both parents agree to advise
the other parent immediately of any emergency medical/dental care sought for the minor
children, to cooperate on health matters concerning the children and to keep one another
reasonably informed. Both parents agree to keep each other informed as to names, addresses
and telephone numbers of all medical/dental care providers.
E. Other Arrangements
Each parent will inform the other parent of any change of address and/or phone number
in advance OR within days of the change.
Both parents will promptly inform the other parent of any emergency or other important
event that involves the minor children.
Both parents will consult and agree with the other parent regarding any extra activity that
affects the minor children’s access to the other parent.
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Each parent will consider the other parent as care-provider for the minor children before
making other arrangements.
Each parent will keep all communication regarding the minor child(ren) between the
parents and will not use the minor child(ren) to convey information or to set up parenting
time changes.
Each parent will encourage love and respect between the minor child(ren) and the other
parent and neither parent shall do anything that may hurt the other parent’s relationship with
the minor children.
Both parents will exert their best efforts to work cooperatively in future plans consistent
with the best interests of the minor children and to amicably resolve such disputes as may
arise.
If either parent is unable to follow through with the time-sharing arrangements involving
the minor child(ren), that parent will notify the other parent as soon as possible.
Both parents agree that if either parent moves out of the area and returns later, they will
use the most recent “Parenting Plan/Access Agreement” in place before the move.
If the parents are unable to reach a mutual agreement regarding a legal change to their
parenting orders, they will request mediation through the court or a private mediator of their
choice.
Obtain Written Consent or Court Order Before Moving: Notice required by ARS 25-408
shall be made by certified mail, return receipt requested, or pursuant to the Arizona rules of
family law procedure. The court shall sanction a parent who, without good cause, does not
comply with the notification requirements of this law. The court may impose a sanction that
will affect the legal decision-making or parenting time only in accordance with the child’s best
interests.
Parental Access to Records and Information Pursuant to Arizona law, unless otherwise
provided by court order or law, on reasonable request both parents are entitled to have equal
access to documents and other information concerning the minor child(ren)’s education and
physical, mental, moral and emotional health including medical, school, police, court and other
records. A person who does not comply with a reasonable request for these records shall
reimburse the requesting parent for court costs and attorney fees incurred by that parent to
make the other parent obey this request. A parent who attempts to restrict the release of
documents or information by the custodian of the records without prior court order is subject
to legal sanctions.
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Notice: Do not deviate from Parenting Plan until dispute is resolved. Both parents are
advised that while a dispute is being resolved, neither parent shall deviate from this Parenting
Plan or act in a way that is inconsistent with the terms of this agreement.
Once this plan has been made an order of the Court, if either parent disobeys the court order
related to parenting time with the children, the other parent may submit court papers to
request enforcement.
SIGNATURE OF ONE OR BOTH PARENTS
Signature of Petitioner: Date:
Signature of Respondent: Date:
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IF YOU ARE REQUESTING SOLE LEGAL DECISION MAKING, THE FORM IS
COMPLETE. DO NOT SIGN SECTION F OR G.
F. STATEMENT REGARDING CONTACT WITH SEX OFFENDERS AND
PERSONS CONVICTED OF DANGEROUS CRIMES AGAINST CHILDREN.
According to A.R.S. §25-403.05, a child’s parent or custodian must immediately notify the other
parent or custodian if the person knows that a convicted or registered sex offender or someone who
has been convicted of a dangerous crime against children may have access to the child.
According to A.R.S. §13-705 (P) (1), “Dangerous crime against children” means any of the following
that is committed against a minor who is under fifteen years of age:
(a) Second degree murder.
(b) Aggravated assault resulting in serious physical injury or involving the discharge, use or
threatening exhibit on of a deadly weapon or dangerous instrument.
(c) Sexual assault.
(d) Molestation of a child.
(e) Sexual conduct with a minor.
(f) Commercial sexual exploitation of a minor.
(g) Sexual exploitation of a minor.
(h) Child abuse as prescribed in section 13-3623, subsection A, paragraph 1.
(i) Kidnapping.
(j) Sexual abuse.
(k) Taking a child for the purpose of prostitution as prescribed in section 13-3212.
(l) Child prostitution as prescribed in section 13-3212.
(m) Involving or using minors in drug offenses.
(n) Continuous sexual abuse of a child.
(o) Attempted first-degree murder.
(p) Sex trafficking.
(q) Manufacturing methamphetamine under circumstances that causes physical injury to a minor.
(r) Bestiality as prescribed in section 13-1411, subsection A, paragraph 2.
(s) Luring a minor for sexual exploitation.
(t) Aggravated luring a minor for sexual exploitation.
(u) Unlawful age misrepresentation.
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The parent or custodian must provide notice by first class mail, return receipt requested, by electronic
means to an electronic mail address that the recipient provided to the parent or custodian for
notification purposes or by another form of communication accepted by the court.
I/We have read, understand, and agree to abide by the requirements of A.R.S. §25-403.05(B)
concerning notification of other parent or custodian if someone convicted of dangerous crime against
children may have access to the child.
Signature of Petitioner: Date:
Signature of Respondent: Date:
G. JOINT LEGAL DECISION-MAKING: If requested or agreed to by the parties, the
following will apply, subject to approval by the Judge:
1. DOMESTIC VIOLENCE: Arizona Law (A.R.S. §25-403.03) states that joint Legal
Decision-Making shall NOT be awarded if there has been “a history of significant domestic
violence”.
Domestic Violence has not occurred between the parties, OR
Domestic Violence has occurred but it has not been “significant” or has been committed
by both parties.* Complete Section 3 below.
2. DUI or DRUG CONVICTIONS:
Neither party has been convicted of driving under the influence or a drug offense within
the past 12 months, OR
One of the parties HAS been convicted of driving under the influence or a drug offense
within the past 12 months, but the parties feel Joint Legal Decision-Making is in the best
interest of the children. * Complete Section 3 below.
3. * IF THERE HAS BEEN DOMESTIC VIOLENCE OR A DUI OR DRUG
CONVICTION:
Explain why Joint Legal Decision-Making is still in the best interests of the children:
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4. REVIEW: The parents agree to review the terms of the / this agreement and make any
necessary or desired changes every months from the date of this document.
5. CRITERIA. Our joint Legal Decision-Making agreement meets the criteria required by
Arizona law A.R.S. §25-403.02, as listed below:
a. The best interest of the minor children are served;
b. Each parent’s rights and responsibilities for personal care of the minor children and
for decisions in education, health care and religious training are designated in this Plan;
c. A schedule of the physical residence of the minor children, including holidays and
school vacations is included in the Plan;
d. The Plan includes a procedure for periodic review;
e. The Plan includes a procedure by which proposed changes, disputes and alleged
breaches may be mediated or resolved;
f. A procedure for communicating with each other about the child, including methods
and frequency.
SIGNATURE OF PARENT(S) REQUESTING JOINT LEGAL DECISION-MAKING
Signature of Petitioner: Date:
Signature of Respondent: Date:
Case Number: S1100DO2