Superior Court of Arizona in Yavapai County Page 11 of 12 DRDC10f
January 2020
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. CHILD SUPPORT: There is no child support order for the minor child(ren) and the court should order
child support in this case.
[ ] O
rder child support be paid by me or the other party in an amount as determined by the Court
under the Arizona Child Support Guidelines and according to the Parent’s Worksheet filed with this
matter.
[
] Order an amount of child support that deviates from the Guidelines because:
[
] Application of the Guidelines is inappropriate or unjust because:
_____________________________________________________________________________
_____________________________________________________________________________
[
] The parties signed an agreement free of duress and coercion, with knowledge of the amount
of support that would have been ordered by the Guidelines but for the agreement. A copy of the
agreement is attached.
[
] Order [ ] Petitioner [ ] Respondent to pay past support in an amount determined using the
Arizona Child Support Guidelines, taking into account any temporary or voluntary/direct support
payments made, the period beginning:
[
] the date this petition was filed until 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.
[
] Petitioner [ ] Respondent made temporary or voluntary/direct support payments that need to be
taken into account if past support is requested.
Child support payments to begin on the first day of the month after the judge or commissioner
signs the __________ a final order. All payments, plus the statutory handling fee, to be paid through
the Support Payment Clearinghouse. P.O. Box 52107, Phoenix, AZ 85072-2107 by income
withholding order.
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1. HEALTH, MEDICAL, DENTAL INSURANCE AND HEALTH CARE EXPENSES FOR CHILD(REN):
Order that [ ] Petitioner or [ ] Respondent shall pay for health, medical, dental insurance coverage
for the child(ren) under the age of 18 years, and that [ ] Petitioner or [ ] Respondent shall pay for all
reasonable unreimbursed medical, dental, health-related expenses incurred for the child(ren) i
n
pr
oportion to their respective incomes as described on the Child Support Worksheet, which shall
be
f
iled with this Petition.
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2. TAX EXEMPTION: The parties will claim the child(ren) as income tax dependency exemptions
on
f
ederal and state income tax returns and as allowed by federal and state tax laws as follows:
Parent entitled to claim Name of child Current tax year Later tax years
[ ] Mother [ ] Father
[ ] Mother [ ] Father
[ ] Mother [ ] Father
[ ] Mother [ ] Father