General Testimony Page 7
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30GENERAL TESTIMONY, PAGE 6a
Initiating IV-D Case No.
Obligor's Payment History
Adjudicated Arrears $____________________ as of ____________________
Date of Order
Year: ______________________
Year: ______________________
Amount Due
Amount Paid
Balance
Amount Due
Amount Paid
Balance
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Total
Year: ______________________
Year: ______________________
Amount Due
Amount Paid
Balance
Amount Due
Amount Paid
Balance
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Total
Total of Adjudicated and Accrued Arrears $_____________________ as of ___________________________
Date
________________________
__________________________________________
____________________________________
Date
Name/Title, Agency or Tribunal
Signature
________________________
__________________________________________
____________________________________
Sworn to and Signed before me
Notary Public, Tribunal/Agency
Commission Expires
this Date, County, State
Official and Title
General Testimony
Page 6a of 10
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