FL 420 DECLARATION OF PAYMENT HISTORY (Family Law—Governmental—Uniform Parentage Act) Fl420
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FL-420 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 To keep other people from seeing what you entered on your form, please press the Clear This Form button at the end of the form when finished. FAX NO. (Optional): E–MAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT: CASE NUMBER: DECLARATION OF PAYMENT HISTORY 1. Declaration of (name): 2. 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): a. b. c. Child support Spousal support Family support d. e. f. Medical support Unreimbursed medical expenses Unreimbursed child care expenses g. Other (specify): 3. Number of pages attached: I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. 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: CHILD SUPPORT: SPOUSAL SUPPORT: FAMILY SUPPORT: MEDICAL SUPPORT: UNREIMBURSED MEDICAL EXPENSES: UNREIMBURSED CHILD CARE EXPENSES: OTHER (specify): Interest (optional): Total Arrearage: $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ NOTICE: Interest that is not calculated is not waived Date: Submitted by: (SIGNATURE) (TYPE OR PRINT NAME) Details of the arrearage statement, consisting of (specify number) Form Adopted for Mandatory Use Judicial Council of California FL-420 [Rev. January 1, 2003] pages, are attached. Page 1 of 1 DECLARATION OF PAYMENT HISTORY (Family Law—Governmental—Uniform Parentage Act) For your protection and privacy, please press the Clear This Form button after you have printed the form. Save This Form Print This Form Family Code, §§ 5230.5, 17524(a), 17526(c) www.courtinfo.ca.gov Clear This Form
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