REQUEST TO MODIFY CHILD SUPPORT - PINAL COUNTY - (SIMPLIFIED PROCEDURES)
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Revised 09.29.15
REQUEST TO
MODIFY CHILD SUPPORT
(SIMPLIFIED PROCEDURES)
PINAL COUNTY
To Change Only the Current Monthly Child Support Amount
INSTRUCTIONS AND FORMS
Provided as a Public Service by
AMANDA STANFORD
Clerk of the Superior CourtINSTRUCTIONS
How to complete Request to Modify Child Support
(Simplified Procedures)
COMPLETE THIS FORM IF:
You have an Arizona child support order and believe the amount of support should be
changed, AND
You have completed a “Parent's Worksheet for Child Support Amount” and it results in a
child support amount (item 38) that varies 15% or more from the amount of your current
order.
TO COMPLETE THIS FORM YOU WILL NEED:
A copy of your current Arizona Child Support Order
A completed Parent's Worksheet for Child Support Amount
NOTE: Generally you should file this Request for Modification in the County where the order you
are seeking to modify was filed.
NOTE: There will be a charge for filing this request. There may be other charges including an
appearance fee if this is your first appearance in this case. If you are unable to pay these
amounts, they can be waived or deferred. The Clerk of the Superior Court has the necessary
forms to ask for a waiver or deferral.
WHEN YOU HAVE COMPLETED THIS FORM:
File the following forms with the Clerk of the Superior Court:
1. Request to Modify Child Support
2. A Completed Parent's Worksheet for Child Support Amount
3. A proposed Child Support Order.
4. An Income Withholding Order completed according to the directions for that form.
Follow these instructions which are numbered to match the identifying numbers on the
form. Please type or print neatly using black ink.
(1) Enter the name, address, and phone number of the person filing the form. Indicate if the
petitioner or the respondent is the person filing, and whether or not the person is self-
represented or represented by an attorney.
(2) Enter the name of the county where you are filing this Request to Modify.
(3) Enter the name of the person shown as the petitioner on your order for child support.
(4) Enter the name of the person shown as the respondent on your order for child support.
(5) Enter the case number that appears on your Arizona Child Support Order.
(6) Select petitioner or respondent to identify the party requesting the modification.
(7) Enter the date on which the judge or commissioner signed your current child support
order.
(8) Enter the name of the judge or commissioner who signed your current child support
order.
(9) Check the appropriate boxes indicating whether Mother, Father, or neither party has
Page 1 of 3 DO_RMCS_COSCPinal_09.29.15
Use only most current versionbeen ordered to provide medical, dental, and vision care insurance.
(10) Check whether Mother or Father has been ordered to make child support payments.
(11) Fill in the amount and payment due date of your current child support order as it was
ordered by the court. (EXAMPLE: $150 per month payable on the 1st day of the month or
$150 per month payable one-half on the first and one-half on the 15th of the month).
(12) Fill in the amount calculated from the completed Parent's Worksheet for Child Support
Amount.
(13) Calculate the percentage of change between your current support amount and the
amount calculated pursuant to the Parent's Worksheet for Child Support Amount. To
determine the percentage, subtract the larger amount from the smaller amount. Divide
that number by the current support amount.
a. Fill in the difference between the amount of child support ordered and the
amount requested to be ordered.
b. Fill in the amount of the child support currently ordered.
c. the percentage change calculated by dividing the amount for "a" by the amount
for "b".
EXAMPLE: The current child support order is $225. The Parent’s Worksheet
calculation result is $270. $270 - $225 = 45 ÷ $225 = 20%.
(14) If the box for item (14) is marked "yes" indicating that one of the parties is using the child
support enforcement services of the Division of Child Support Enforcement (DCSE),
notice of this action must be given to that DCSE office. You may drop it off or mail it to
your local office. Find a child support office location nearest to you at:
FindOfficeFormazdes.gov. If you live in Maricopa County, mail a copy of the "Request to
Modify Child Support" and a copy of the "Parent's Worksheet for Child Support Amount"
to:
DES Division of Child Support Services
ATTN: Modification
P.O. Box 40458
Phoenix, AZ 85067
Serve the following items on the other party:
A copy of your completed "Request to Modify Child Support," and
A copy of your completed “Parent's Worksheet for Child Support Amount."
Some counties also REQUIRE that you serve these items:
A blank copy of the Request for Hearing and Notice of Hearing form with
instructions, and
A blank copy of the Parent's Worksheet for Child Support Amount with
instructions.
To "serve” means to use the legally required method of delivering notice or documents,
pursuant to Rules 40, 41, and 42, of the Arizona Rules of Family Law Procedure. The
most common method of service on a party is personal service by a private process
server or sheriff. Process servers are listed in the yellow pages and on the internet.
When service has been completed, file proof of service with the Clerk of Superior Court.
The Affidavit of Service is usually prepared by the person serving the document,
indicating the date and time service was made.
Page 2 of 3 DO_RMCS_COSCPinal_09.29.15
Use only most current version(15) If there are other court-ordered payments included in the current Income Withholding
Order, enter the date the Income Withholding Order was signed, and the amounts and
frequency of payments ordered.
(16) Enter the amount of child support being requested that was calculated in the Parent’s
Worksheet.
(17) Check the appropriate boxes indicating responsibility for providing medical, dental, and
vision care insurance.
(18) Enter the amount each parent will contribute for medical/dental/vision care expenses not
paid by insurance. Indicate as a percentage.
(19) The party filing the request for a change in child support order must date and sign this
document. By signing, you are stating under oath, or affirming, that the contents of this
request are true and correct under penalty of perjury.
Page 3 of 3 DO_RMCS_COSCPinal_09.29.15
Use only most current versionPROCEDURES
What to Do After You Have Completed Request to Modify Child Support Forms
STEP 1: MAKE TWO COPIES* (or 3, if the State DES/ Dept of Child Support Enforcement is
involved) of the:
Request to Modify Child Support and Parent’s Worksheet
STEP 2: Separate your papers into three sets* (4, if DES or Dept of Child Support Enforcement is
involved)
Set 1 – ORIGINALS for the Clerk of Superior Court: Set 2 – COPY for the Other Party
(1) Original Request to Modify Child Support (1) Request to Modify Child Support
(2) Original Parent’s Worksheet (2) Parent’s Worksheet
(3) Child Support Order (3) Instructions and forms for Request for
(4) Income Withholding Order/Notice for Support Hearing and Notice of Hearing
(5) Employer Information Sheet
AND
(1) 2 Self Addressed, Stamped envelopes:
(2) One addressed to you;
(3) One addressed to the Other Party
Set 3 – COPY for You Set 4 – COPY for State (*if required)
(1) Request to Modify Child Support (1) Request to Modify Child Support
(2) Parent’s Worksheet” (2) Parent’s Worksheet
(3) Acceptance of Service
STEP 3: FILE THE PAPERS WITH THE CLERK OF THE COURT. We have three office locations
where you can file your papers:
Pinal County Justice Complex Apache Junction Office
971 N. Jason Lopez Circle Bldg. A 575 N. Idaho Rd. Suite 109
Florence AZ 85132 Apache Junction, AZ 85119
(520) 866-5300 (520) 866-5300
Fax (520) 866-5320 Fax (520) 866-6170
Casa Grande Office Mammoth Office
820 E. Cottonwood Lane Bldg. B (Temporarily Closed)
Casa Grande, AZ 85122
(520) 866-5300
Fax (520) 866-7481
FILING FEE: There is a fee for filing this Petition and there may be other charges
associated with this process. Inquire with the Clerk’s office regarding the filing fee
amount. The fee is payable to the Clerk of the Superior Court by money order, personal
check with proper identification, Cash, Visa, MasterCard, debit or credit.
Go online to http://www.coscpinalcountyaz.gov/fees.html for current filing fees.
Page 1 of 2 DO_RMCS_COSCPinal_09.29.15
Use only most current versionIf you cannot pay these fees, you may request the fee(s) be deferred or waived. The
Clerk of the Superior Court has the necessary forms to ask for a deferral or waiver. With
the Application for Deferral, you must provide proof of income (copy of your last 2 most
recently paystubs).
Hand the originals and all set of copies to the clerk at the filing counter and along with
your method of payment. The Clerk will keep the original, stamp the extra copies to show
that the original document was filed with the Court. The clerk will return the stamped
copies to you. The stamped copies are called “conformed” copies.
STEP 4: MAKE SURE YOU GET BACK FROM THE DEPUTY CLERK THE FOLLOWING:
Your conform copy
The other party’s stamped copy
The copy for DES / Dept of Child Support Services (if required)
STEP 5: SERVE THE PAPERS ON THE OTHER PARTY(IES). The copy of the Request to
Modify and Parent’s Worksheet may be delivered by the Sheriff’s Office, a licensed
process server, commercial delivery service or mail by which you can obtain an original
or copy of the other party’s signature confirming delivery, or by an notarized Acceptance
of Service, signed by the other party(ies). Whatever method you choose, the original
proof of service must be filed with the Clerk of the Court.
Serves on the State of Arizona: If the Attorney General’s Child Support Services
Section has been involved with your case, you MUST also serve the Attorney General’s
office. The Attorney General’s office will ACCEPT service. You must deliver an
Acceptance of Service form to the Child Support Services Section of the Attorney
General’s office:
Attorney General’s Office
Child Support Services Section
PO Box 608
Florence Arizona 85132
Site Code: 039-A
After the Attorney General’s office signs the Acceptance of Service, you MUST file the
original signed Acceptance of Service with the Clerk of the Court.
STEP 6: WAIT. If the other party is served in the State of Arizona, the person has 20 days from
the date of service to file a Request for Hearing. If the party is served outside of Arizona
has 30 days from the date of service to file a Request for Hearing.
If a Request for Hearing is filed and a hearing is set, you will receive written notice of the
date, time and location to appear for Court. OR
After the time has lapsed and no party requests a hearing, the Judge may grant your
request and sign the Income Withholding Order/Notice for Support. OR
The Judge may schedule a hearing to obtain further information and all parties will
receive written notice of the date, time and location to appear for Court.
For more information review the Rules of Family Law Procedures.
Forms can be found at: http://www.coscpinalcountyaz.gov/forms.html
Page 2 of 2 DO_RMCS_COSCPinal_09.29.15
Use only most current versionPARENT’S WORKSHEET FOR CHILD SUPPORT AMOUNT
Prepared By (1): Petitioner Respondent Judiciary Court Staff IV-D Agency
Name of person filing: (2) Date prepared (3)
Petitioner (4) Case No. (6)
Respondent (5) ATLAS No. (7)
Time-sharing arrangement (8): Essentially equal Mostly with Father Mostly with Mother
(9) Child(ren)’s names (First, Middle Initial, and last name Date of birth (mo/day/year) Age
Presumptive termination date Actual termination date Youngest grade .
Number of minor children Number of children age 12 or over .
Father Mother
Gross Monthly Income (10) $ $ .
Spousal maintenance paid (11) $- $- .
Spousal maintenance received (12) $+ $+ .
Custodial parent of other children subject of court order(s) (13)
Father Mother $- $- .
Court-ordered child support paid for children of other relationships (14) $- $- .
Other natural or adopted children not subject of court order(s) (15)
Father Mother $- $- .
Standard deduction $- $- .
Alternate Deduction (only of less than standard deduction) $- $- .
Adjusted Gross Monthly Income (16) $ $ .
Combined Adjusted Gross Income (17) $ .
Basic Child Support Obligation for children (18) $ .
Additions:
Adjusted for children over age 12 at % (19) $ .
Medical, dental and vision insurance paid (20) $ $ .
Monthly childcare costs (21) for child(ren) $ $ .
Less deferral tax credit allowed to custodian at % $ $ .
Extra education expenses paid (22) $ $ .
Extraordinary (gifted or handicapped) child expenses paid (23) $ $ .
Subtotal (24) $ $ .
Total Adjustments for Costs (25) $ .
Total Child Support Obligation (26) $ .
Each parent’s proportionate percentage of combined income (27) % %
Each parent’s proportionate share of the total support obligation (28) $ $ .
Less paying parent’s costs (29) $ $ .
Page 1 of 2 DO_PW_COSCPinal_03.26.13
Use only most current versionPARENT’S WORKSHEET FOR CHILD SUPPORT AMOUNT
Costs associated with parenting time (30): Table A Table B
No. of days
Line (18) x % $ $ .
Adjustments subtotal (31) $ $ .
Preliminary Child Support Amount (32) $ $ .
Self-Support Reserve Test for Payor (33)
Line (16) $ Less paid arrears $ Less $903 $ $ .
Child support amount to be paid by (34): Father Mother $ $ .
Travel related to parenting time (35) % %
Medical, dental, and vision costs not paid by insurance (36) % %
Page 2 of 2 DO_PW_COSCPinal_03.26.13
Use only most current version(1)
Name of Person Filing:
Person filing is the: Petitioner Respondent
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 (2) COUNTY
(3) (5) CASE NUMBER: DO2
Name of Petitioner
REQUEST TO MODIFY CHILD SUPPORT
PURSUANT TO GUIDELINES SIMPLIFIED
PROCEDURES
(4)
Name of Respondent
IMPORTANT NOTICE TO PARTY NOT REQUESTING THE MODIFICATION
Your support order may be modified if you do not request a hearing.
(6) The Petitioner, or Respondent asks this court to modify the Arizona child support order in this case
entered on (7) / / by (8)
(month / day / year) (Name of judge or commissioner)
A. Under the current child support order (9):
Mother is responsible for providing medical dental vision care insurance
Father is responsible for providing medical dental vision care insurance
Neither party was ordered to provide medical dental vision care insurance
B. The child support currently in effect requires (10) Mother, or the Father to make
payments of (11) $ per month, payable on the day of the month.
C. Attached is a Parent’s Worksheet for Child Support Amount. According to the worksheet calculations the
child support amount should be (12) $ per month.
D. The following calculations show that the requested change varies from the current-ordered child support
amount by 15% or more.
(13) (a) divided by (b) equals (c) %
a = the difference between the amount currently ordered and the amount requested
b = the amount currently ordered; and
c = the percentage change
Page 1 of 3 DO_RMCS_COSCPinal_03.25.13
Use only most current versionE. Is the Division of Child Support Enforcement (DCSE) providing child support enforcement services for at least
one of the parties? (14) Yes No Unknown (If “Yes” is selected, see instructions for providing notice
to the State.)
F. Other court-ordered payments included in the current Income Withholding Order dated:
(15) / / (month/day/year)
Current Spousal Maintenance: $ per
Payments on Child Support Arrearages/Interest: $ per
Payments on Spousal Maintenance Arrearages/Interest $ per
Other: $ per
Clearinghouse Handling Fee $ 5.00 per month
RELIEF REQUESTED OF THIS COURT:
1. I request that child support be ordered in the amount of (16) $____________ per month to be paid by the
Mother or the Father, and that relief requested in the Parent’s Worksheet be ordered.
2. REGARDING INSURANCE FOR MINOR CHILDREN, order that (17):
Mother is responsible for providing medical dental vision care insurance
Father is responsible for providing medical dental vision care insurance
The costs of medical/dental/vision care expenses not paid by insurance shall be shared as follows: (18)
Mother __________% Father _________%. Request for payment or reimbursement must be provided to
the obligated parent(s) within 180 days after the services occurred. The obligated parent must pay or
make payment arrangements with 45 days after receipt of the request.
3. If this matter goes to hearing, I further request that costs and fees incurred in bringing this action be
ordered to be paid by the opposing party.
OATH OR AFFIRMATION
I affirm the contents of this document are true and correct under penalty of perjury.
Date Signature
State of Arizona )
)
County of )
SUBSCRIBED AND SWORN TO before me this day of , 20
by
Name of Signer
Commission Expires Notary Public
Page 2 of 3 DO_RMCS_COSCPinal_03.25.13
Use only most current versionNOTICE TO PARTIES
If you do not agree with the modification, you have twenty days in which to ask for a hearing on the requested modification. If
service of process is made outside the State of Arizona, the parent receiving service has 30 days in which to ask for a hearing
on the requested modification.
Upon proof of service and if no hearing is requested within the time allowed, the court will review the request and enter an
appropriate order modifying the support award. If an error is noted the amount awarded may be different from the amount
requested, but there will be no greater modification then requested.
In the event the court has serious concerns regarding the accuracy of the information, or if a substantial mathematical error is
found, the court may set the matter for hearing. If either party requests a hearing within the time allowed, the court shall
conduct the hearing. No order shall be modified without a hearing if one is requested.
If you wish to request a hearing, you may obtain the flowing forms from the office of the Clerk of the Superior Court. These
forms may be in your packet.
● Request for Hearing and Notice of Hearing
● Parent’s Worksheet for Child Support Amount
Page 3 of 3 DO_RMCS_COSCPinal_03.25.13
Use only most current versionCHILD 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.
Calculate Support for Parent’s Worksheet
Your computer must be connected to a printer. Begin by selecting which Child Support Calculator applies to you, 2005 or 2011, 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
Page 1 of 1 DO_CSC_COSCPinal_12.18.14
Use only most current version(1) Name of Person Filing: _____________________________
Person filing is the: Petitioner Respondent
Mailing Address (if not protected): ______________________
City, State, Zip Code: _________________________________
Phone Number: ______________________________________
Representing Self, Without an Attorney
(If Attorney) State Bar Number: _________________________
Attorney E-Mail Address: ______________________________ For Clerk Use Only
SUPERIOR COURT OF ARIZONA COUNTY OF (2) _____________________
) (5) Case No.
) _______________________________
(3)___________________________________ )
Petitioner )
)
)
and ) (6) ATLAS No. _____________________
)
)
(4)___________________________________ )
Respondent )
______________________________________ ) CHILD SUPPORT ORDER
THE COURT FINDS that:
1. (7)_________________, Father and (8)________________ Mother, owe a duty to support the following
child(ren):
Name Date of Birth
(9) ________________________________ ___________________________________
___________________________________ ___________________________________
___________________________________ ___________________________________
___________________________________ ___________________________________
___________________________________ ___________________________________
___________________________________ ___________________________________
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 Child Support Worksheet, attached and incorporated herein by
reference.
3. Child Support.
(10a) [ ] Father [ ] Mother is obligated to pay child support to [ ] Father [ ] Mother in the amount of
$________per month pursuant to the Arizona Child Support Guidelines without deviation.
(10b) [ ] Father [ ] Mother is obligated to pay child support to [ ] Father [ ] Mother 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
Arizona Supreme Court – Self Service Center
January 2013
Child Support OrderCase No._____________________
appropriate and just to make a rounding adjustment to the exact guideline amount for ease of calculation
to $___________ per month.
(11a) [ ] Father [ ] Mother is obligated to pay child support to [ ] Father [ ] Mother 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.
(11b) [ ] Father [ ] Mother is obligated to pay child support to [ ] Father [ ] Mother 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.
Fill in the reason(s) for deviation below if (11a) or (11b) was selected.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
4. Support Arrears.
(12a) [ ] Father [ ] Mother owes child support arrearages to [ ] Father [ ] Mother in the total amount of
$_____________for the time period of ____________ through __________ plus accrued interest on prior
child support arrearages due of $____________ calculated thru the date of ____________.
(12b) [ ] The court finds no child support arrearages due and owing.
(12c) [ ] No evidence was presented in support of child support arrearages.
5. Past Support.
(13a) [ ] It is appropriate to award [ ] Father [ ] Mother 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.
(13b) [ ] It is appropriate to award [ ] Father [ ] Mother 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.
(13c) [ ] The court finds no past support amount due and owing.
(13d) [ ] No evidence was presented in support of past child support.
IT IS ORDERED that:
A. Child Support.
(14) [ ] Father [ ] Mother shall pay child support to [ ] Father [ ] Mother in the sum of
$_________________ per month payable by wage assignment on the first day of each month
commencing ______________.
B. Support Arrearages Judgment.
(15a) [ ] Father [ ] Mother is granted judgment against [ ] Father [ ] Mother in the sum of
$______________ as and for child support arrearages for the period of _________________ thru 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 thru
Page 2 of 5Case No._____________________
the date of _________ . [ ] Father [ ] Mother 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.
(15b) [ ] No judgment for child support arrearages is entered.
C. Past Support Judgment.
(16a) [ ] Father [ ] Mother is granted a past support judgment against [ ] Father [ ] Mother in the
additional amount of $___________. [ ] Father [ ] Mother shall pay the additional amount of
$____________ per month toward this judgment, payable on the first day of each month commencing
_________________ until paid in full.
(16b) [ ] 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 remains responsible for the full monthly amount
ordered. Payments not made directly through the Support Payment Clearinghouse shall 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
(17) Payments must include the [ ] Father’s [ ] Mother’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 shall submit the names and
addresses of their employers or other payors within 10 days. The parties shall submit address changes
within 10 days of the change.
E. Total Monthly Payments.
(18) [ ] Father [ ] Mother shall make total monthly payments to [ ] Father [ ] Mother of $______ per
month payable on the first day of each month commencing ______________ as follows:
Monthly Payments: Current child support payment as ordered above: $ ___________
Child support arrearage payments: $ ___________
Current spousal maintenance payment: $ ___________
Past due spousal maintenance payment: $ ___________
Clearinghouse handling fee: $ 5.00
Total monthly payment: $ ___________
F. Non-Covered Medical Expenses.
(19) [ ] Father [ ] Mother is ordered to pay____________% and [ ] Father [ ] Mother 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 parent within 180 days after the date the
services occur. The parent 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.
Page 3 of 5Case No._____________________
G. Medical, Dental, and Vision Insurance (A.R.S. § 25-320(J)).
(20a) [ ] Father [ ] Mother 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 guidelines worksheet.
(20b) [ ] Father [ ] Mother 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 parent 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 Amount attached hereto and incorporated by reference. The parent
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 parent. Notification must also be provided to the other
parent if coverage is no longer being provided for the child(ren).
H. Travel Expenses.
(21) The costs of travel related to parenting time over 100 miles away shall be shared as follows:
Father_____________________% Mother_____________________%
I. (22) 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.
K. (23)Tax Exemptions.
The Court allocates tax exemptions for the dependent children as follows:
Child’s Name Date of Birth Parent Entitled to Deduction for Each
Calendar Year
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.
(23a) [ ] Father [ ] Mother may claim the allocated tax exemptions only if all child support and arrears
ordered for the year have been paid by December 31 of that year.
(23b) [ ] Father [ ] Mother may unconditionally claim the tax exemptions allocated to [ ] him [ ] her for
income tax purposes.
Page 4 of 5Case No._____________________
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.
M. Emancipation.
Although the obligation to pay support may continue, 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 but only until the child graduates or 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
______________________________________
Printed Name of Judicial Officer
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.
________________________________________ _______________________________________
Obligor Date Obligee Date
________________________________________ _____________________________________
Attorney for Obligor Date Attorney for Obligee Date
Page 5 of 5INSTRUCTIONS AND FORM
Request for Hearing and Notice of Hearing
(Simplified Modification)
COMPLETE THIS FORM IF:
A Request to Modify Child Support Pursuant to Guidelines’ Simplified Procedure has been filed, AND
You want to have a hearing to explain your position.
TO REQUEST A HEARING YOU WILL NEED:
A copy of the Request to Modify Child Support, AND
A completed “Parent’s Worksheet for Child Support Amount.”
NOTE: There may be a charge for filing this Request. There may be other charges including an
appearances fee if this is your first appearance in this case. If you cannot pay these fees, you may
request the fees be deferred or waived. The Clerk of the Superior Court has the necessary forms to ask
for a deferral or waiver.
FOLLOW THESE INSTRUCTIONS NUMBERED TO MATCH THE IDENTIFYING NUMBERS ON THE
FORM. TYPE OR PRINT NEATLY USING BLACK INK.
(1) Fill in the name, address, and phone number of the person filing the form. (The spaces marked
representing and state bar number is used only if an attorney is preparing this form).
(2) Fill in the name of the county that appears in this space on the Request to Modify Child Support.
(This may already be printed on the form).
(3) Fill in the name of the person shown as the petitioner on the Request to Modify Child Support.
(4) Fill in the name of the person shown as the respondent on the Request to Modify Child Support.
(5) Fill in the case number that appears on the Request to Modify Child Support.
(6) Date and sign here before a Notary Public or a Deputy Clerk of the Court. By signing, you are stating
under oath that the contents of this Request for Hearing are true and correct to the best of your
knowledge.
(7) Leave this area blank; it will be completely by personnel at the Office of the Clerk of the Superior
Court when you file these documents.
(8) List the name and current mailing address of the other party to this action. If you are using the child
support services of the Department of Economic Security (DES) or if the other party answered YES to
item 13 on the Request to Modify Child Support, you MUST also mail a copy of this Request for
Hearing and Notice of Hearing to the Department of Economic Security.
(9) Sign and date the form to indicate that you will mail the Request for Hearing and Notice of Hearing as
indicated.
Page 1 of 2 DO_RHNH_COSCPinal_11.30.12
Use only most current versionWHEN YOU HAVE COMPLETED THIS FORM GO TO THE OFFICE OF THE CLERK OF THE
SUPERIOR COURT TO FILE YOUR PAPERS:
You should arrive at the Clerk’s Office at least two hours before it closes. You may file your court papers
at the following locations:
Pinal County Justice Complex Apache Junction Office
971 N. Jason Lopez Circle Bldg. A 575 N. Idaho Rd. Suite 109
Florence AZ 85132 Apache Junction, AZ 85119
(520) 866-5300 (520) 866-5300
Fax (520) 866-5320 Fax (520) 866-6170
Casa Grande Office Mammoth Office
820 E. Cottonwood Lane Bldg. B (Temporarily Closed)
Casa Grande, AZ 85122
(520) 866-5300
Fax (520) 866-7481
Give the form and your completed Parent’s Worksheet to the Clerk of the Superior Court. The Clerk’s
office will fill in the date, time and place of the Hearing and have the notice signed.
PAPERS: Hand all three (3) sets of your court papers to the deputy clerk along with the filing fee.
The clerk will file stamp and retain the originals and conform stamp your copies.
MAKE SURE YOU PROVIDE (2) STAMPED ENVELOPES IN ORDER TO RECEIVE THE FOLLOWING
FROM THE CLERK:
Your set of Copies – Conformed Stamped
Your Spouse’s Set of Copies – Conformed Stamped
IMMEDIATELY AFTER THE COURT SETS THE HEARING & FILLS IN THE INFORMATION IN
NUMBER 7:
You must mail a copy of the Request for Hearing and Notice of Hearing as indicated in item 8.
Page 2 of 2 DO_RHNH_COSCPinal_11.30.12
Use only most current version(1)
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
(2)PINAL COUNTY
(3) (5) CASE NUMBER: DO2
Name of Petitioner
REQUEST FOR HEARING AND
NOTICE OF HEARING
(Simplified Procedure)
(4)
Name of Respondent HONORABLE:
A Request to Modify Child Support Pursuant to Guidelines’ Simplified Procedures, has been filed.
The information provided in the Parent’s Worksheet that was the basis for the Request to Modify Child Support is
not accurate. I am attaching the required completed Parent’s Worksheet that shows what I believe to be accurate
information. I request that a hearing be set so that I can explain to the judge or commissioner my position. I
further request that costs and fees incurred in responding to the Request for Modification be ordered to be paid by
the opposing party.
I Have Read This Document And The Information Given Here Is True And Correct To The Best Of My Knowledge.
Date Signature
State of Arizona )
)
County of )
SUBSCRIBED AND SWORN TO before me this day of , 20
by
Name of Signer
Commission Expires Notary Public
Page 1 of 2 DO_RHNH_COSCPinal_09.29.15
Use only most current versionNOTICE OF HEARING
The above verified Request for Hearing having been filed, this matter shall be heard:
(7) DATE AND TIME:
at a.m. / p.m.
(Date) (Time)
PLACE: PINAL COUNTY SUPERIOR COURT
971 N. JASON LOPEZ CIRCLE BLDG. A
FLORENCE, AZ 85132
If either party fails to appear at the hearing after proper notice, the court will take evidence from the party who
does appear and make a decision based on the information provided in the Request to Modify Child Support,
Request for Hearing and any oral testimony.
(Date) (Judicial Officer)
Upon receipt of the hearing date, I will immediately mail a copy of this Request for Hearing and Notice of Hearing
to the other parent or such person’s attorney as follows:
(8) NAME:
ADDRESS:
If one of the parties is using the child support services of the Department of Economic Security, I will also
immediately mail a copy of this Request for Hearing and Notice of Hearing to:
Attorney General’s Office
Child Support Services Section
PO Box 608
Florence Arizona 85132
Site Code: 039-A
(9)
(Date) (Requesting Party)
Page 2 of 2 DO_RHNH_COSCPinal_09.29.15
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