Payment Record
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FL-421
PETITIONER/PLAINTIFF:
CASE NUMBER:
RESPONDENT/DEFENDANT:
OTHER PARENT:
PAYMENT HISTORY FOR (check one):
Child
Spousal
Family
Medical
Unreimbursed child care
Other (specify):
Unreimbursed medical
Year
Year
Year
AMOUNT
AMOUNT
AMOUNT
AMOUNT
AMOUNT
AMOUNT
ORDERED
PAID
ORDERED
PAID
PAID
ORDERED
January
February
March
April
May
June
July
August
September
October
November
December
TOTAL
Year
Year
Year
AMOUNT
AMOUNT
AMOUNT
AMOUNT
AMOUNT
AMOUNT
PAID
ORDERED
ORDERED
PAID
ORDERED
PAID
January
February
March
April
May
June
July
August
September
October
November
December
TOTAL
Page 1 of ________
Form Approved for Optional Use
Family Code, §§ 5230.5,
PAYMENT HISTORY ATTACHMENT
Judicial Council of California
17524 (a), 17526(c)
(Family Law—Governmental—Uniform Parentage Act)
FL-421 [Rev. July 1, 2003]
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