FL-420 - Declaration of Payment History (Governmental—Uniform Parentage Act)

Summary

Declaration of Payment History (Governmental—Uniform Parentage Act)

Text

Form ID: FL-420
Title: Declaration of Payment History (Governmental—Uniform Parentage Act)
Effective Date: 2003-01-01
Mandatory Form: yes
Info Page: https://selfhelp.courts.ca.gov/jcc-form/FL-420
Primary Download URL: https://www.courts.ca.gov/documents/fl420.pdf
Form Detail Page:
Declaration of Payment History (Governmental—Uniform Parentage Act)
(FL-420)
Tells the court and the other parent how much support you believe has been paid in your case.
Get form FL-420
Effective: January 1, 2003
PDF Text:
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
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
CITY AND ZIP CODE:
BRANCH NAME:
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT:
CASE NUMBER:
DECLARATION OF PAYMENT HISTORY
Declaration of (name):
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):
Child support
Number of pages attached:
CHILD SUPPORT:
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
NOTICE: Interest that is not calculated is not waived
Date:
(SIGNATURE)(TYPE  OR  PRINT  NAME)
DECLARATION OF PAYMENT HISTORY
(Family Law—Governmental—Uniform Parentage Act)
Family Code, §§ 5230.5,
17524(a), 17526(c)
Form Adopted for Mandatory Use
Judicial Council of California
FL-420 [Rev. January 1, 2003]
STREET ADDRESS:
MAILING ADDRESS:
FL-420
Page 1 of 1
E–MAIL ADDRESS (Optional):
ATTORNEY FOR (Name):
FAX NO. (Optional):
Details of the arrearage statement, consisting of (specify number)          pages, are attached.
1.
2.
3.
a.
b.
c.
d.
e.
f.
Medical support
Spousal support
Family support
Unreimbursed medical expenses
Unreimbursed child care expenses
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: Interest (optional): Total Arrearage:
$
SPOUSAL SUPPORT: $
FAMILY SUPPORT: $
UNREIMBURSED
    MEDICAL EXPENSES: $
UNREIMBURSED
    CHILD CARE EXPENSES: $
OTHER (specify): $
$
$
$
$
$
$
$
$
$
$
$
$
Submitted by:
g. Other (specify):
MEDICAL SUPPORT: $ $ $
www.courtinfo.ca.gov
 Laura Lynn Morgan 31/03 Morgan I Love You

Retrieval chunks

• #1

  Form ID: FL-420 Title: Declaration of Payment History (Governmental—Uniform Parentage Act) Effective Date: 2003-01-01 Mandatory Form: yes Info Page: https://selfhelp.courts.ca.gov/jcc-form/FL-420 Primary Download URL: https://www.courts.ca.gov/documents/fl420.pdf Form Detail Page: Declaration of Payment History…

• #2

  Laura Lynn Morgan 31/03 Morgan I Love You