Request To Modify Child Support Pursuant To Guidelines Simplified Procedure {DRMSS11F}

(1) Name of Person Filing: _________________________________________ Person filing is the: Petitioner Respondent Mailing Address (if not protected):__________________________________ City, State, Zip Code: ____________________________________________ Phone Number: ____________________________________________ I am representing myself, without an attorney (If Attorney) State Bar Number __________________________ Attorney E-Mail Address: _______________________________ For Clerk Use Only SUPERIOR COURT OF ARIZONA IN (2) ________________________ COUNTY (3) (5) Case No. Name of Petitioner (4) Name of Respondent REQUEST TO MODIFY CHILD SUPPORT PURSUANT TO GUIDELINES SIMPLIFIED PROCEDURE 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 Father is responsible for providing Neither party was ordered to provide medical dental vision care insurance medical dental vision care insurance medical dental vision care insurance B. The child support order currently in effect requires the (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) = (c) % a = the difference between the amount currently ordered and the amount requested b = the amount currently ordered; and c = the percentage change E. Is the Division of Child Support Services (DCSS) 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.) E. Other court-ordered payments included in the current Income Withholding Order dated: (15) ___/_____/____ (month/day/year). Arizona Supreme Court ­ Self Service Center July 2013 Request to Modify Child Support ­ Simplified Procedure Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case No. ___________________ Current Spousal Maintenance Payments on Child Support Arrearages/Interest Payments on Spousal Maintenance Arrearages/Interest Other Clearinghouse Handling Fee $ $________ $________ $________ $ 5. 00 per ________ per ________ per ________ per ________ 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. _______________________________________ (19) Requesting Party's Signature ___________________________________________ Printed Name ____________________ Date NOTICE TO PARTIES If you do not agree with the modification to your child support, you have 20 days in which to ask for a hearing. 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. 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 the modification will not be greater than the amount 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 a hearing is requested. If you wish to request a hearing, you may obtain the following forms from the Office of the Clerk of Superior Court. Request for Hearing and Notice of Hearing Parent's Worksheet for Child Support Amount Arizona Supreme Court ­ Self Service Center July 2013 Request to Modify Child Support ­ Simplified Procedure Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com