ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state Bar number, and address) or
GOVERNMENTAL AGENCY (under Family Code, §§ 17400, 17406):
TELEPHONE NO.:
FOR COURT USE ONLY
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
CITY AND ZIP CODE:
BRANCH NAME:
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT:
CASE NUMBER:
DECLARATION OF PAYMENT HISTORY
Declaration of (name):
Based on my records or my recollection, I declare that the information on the attached pages showing the amounts ordered and
the amounts paid are true and correct for the following obligations (check all that apply):
Child support
Number of pages attached:
CHILD SUPPORT:
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
NOTICE: Interest that is not calculated is not waived
Date:
(SIGNATURE)
(TYPE OR PRINT NAME)
DECLARATION OF PAYMENT HISTORY
(Family Law—Governmental—Uniform Parentage Act)
Family Code, §§ 5230.5,
17524(a), 17526(c)
Form Adopted for Mandatory Use
Judicial Council of California
FL-420 [Rev. January 1, 2003]
STREET ADDRESS:
MAILING ADDRESS:
FL-420
Page 1 of 1
E–MAIL ADDRESS (Optional):
ATTORNEY FOR (Name):
FAX NO. (Optional):
Details of the arrearage statement, consisting of (specify number) pages, are attached.
1.
2.
3.
a.
b.
c.
d.
e.
f.
Medical support
Spousal support
Family support
Unreimbursed medical expenses
Unreimbursed child care expenses
Date:
(SIGNATURE OF DECLARANT)
(TYPE OR PRINT NAME)
SUPPORT ARREARAGE SUMMARY
This summary is for arrearage for the periods specified in the attached pages.
Interest is calculated through (specify date):
Principal:
Interest (optional): Total Arrearage:
$
SPOUSAL SUPPORT:
$
FAMILY SUPPORT:
$
UNREIMBURSED
MEDICAL EXPENSES:
$
UNREIMBURSED
CHILD CARE EXPENSES:
$
OTHER (specify):
$
$
$
$
$
$
$
$
$
$
$
$
$
Submitted by:
g.
Other (specify):
MEDICAL SUPPORT:
$
$ $
www.courtinfo.ca.gov
Laura Lynn Morgan 31/03
Morgan I Love You
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