Request To Modify Child Support Pursuant To Guidelines Simplified Procedure Form Page 2
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1
2Case No. ___________________
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.
_______________________________________
____________________
(19) Requesting Party’s Signature
Date
___________________________________________
Printed Name
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
Page 2 of 2
July 2013
Request to Modify Child Support – Simplified Procedure
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