FL-421 - Payment History Attachment (Governmental—Uniform Parentage Act)

Summary

Payment History Attachment (Governmental—Uniform Parentage Act)

Text

Form ID: FL-421
Title: Payment History Attachment (Governmental—Uniform Parentage Act)
Effective Date: 2003-07-01
Mandatory Form: no
Info Page: https://selfhelp.courts.ca.gov/jcc-form/FL-421
Primary Download URL: https://www.courts.ca.gov/documents/fl421.pdf
Form Detail Page:
Payment History Attachment (Governmental—Uniform Parentage Act)
(FL-421)
Gives a monthly breakdown about how much support has been paid and attach to Declaration of Payment History (form FL-420).
Get form FL-421
Effective: July 1, 2003
PDF Text:
PETITIONER/PLAINTIFF: CASE NUMBER:
RESPONDENT/DEFENDANT:
OTHER PARENT:
PAYMENT HISTORY FOR (check one):
Spousal
June
March
May
AMOUNT
ORDERED
January
February
April
July
PAYMENT HISTORY ATTACHMENT
(Family Law—Governmental—Uniform Parentage Act)
Family Code, §§  5230.5, 
17524 (a), 17526(c)
Form Approved for Optional Use
Judicial Council of California
FL-421 [Rev. July 1, 2003]
FL-421
Child Unreimbursed child care
Unreimbursed medical Other (specify):
Year Year Year
AMOUNT
ORDERED
AMOUNT
ORDERED
AMOUNT
PAID
AMOUNT
PAID
AMOUNT
PAID
August
September
October
November
December
TOTAL
June
March
May
AMOUNT
ORDERED
January
February
April
July
Year Year Year
AMOUNT
ORDERED
AMOUNT
ORDERED
AMOUNT
PAID
AMOUNT
PAID
AMOUNT
PAID
August
September
October
November
December
TOTAL
Page 1 of ________
MedicalFamily
www.courtinfo.ca.gov

PAYMENT HISTORY ATTACHMENT
(Family Law—Governmental—Uniform Parentage Act)
FL-421 [Rev. July 1, 2003]
INSTRUCTIONS FOR COMPLETING PAYMENT RECORD
You must complete a separate Payment History Attachment form for each type of support paid. Enter the year, list 
the amount ordered, and the amount paid for each month during that year. If the amounts repeat in a column, you can use 
an arrow as shown in the example below. Add the amounts in each column to get the yearly totals. Enter the totals at the 
bottom.
Attach additional sheets and supporting documents (bills, receipts, and other proof of expense) as necessary.
June
March
May
AMOUNT
ORDERED
January
February
April
July
Year Year
AMOUNT
ORDERED
AMOUNT
PAID
AMOUNT
PAID
August
September
October
November
December
TOTAL
2000 2001
100
1,200 600 1,200 400
0
0
100
100
100
100
100 100
0
100
0
100
100
0
Childx
June
March
May
AMOUNT
ORDERED
January
February
April
July
AMOUNT
PAID
August
September
October
November
December
TOTAL
100
1,200 600
0
100
100
0
100
Spousalx
100
You must complete a separate Payment History Attachment form for each type of unreimbursed expense. If you have more than one 
bill, receipt, and other proof of expense per month use an additional declaration page (form MC-031) or separate page. 1.) Itemize each 
expense; 2.) attach proof of bill or payment; 3.) mark each bill or payment with an Exhibit # _____; 4.) group the bills, receipts, and 
other proof of expense in chronological order for each month; and 5.) enter the total bills, receipts, and other proof of expense for each 
month. If your court order did not state a specific due date for reimbursement, then include that amount in the month that the expense 
was incurred.
UNREIMBURSED CHILD CARE, MEDICAL, OR OTHER EXPENSES:
June
March
May
AMOUNT
ORDERED
January
February
April
July
Year
AMOUNT
PAID
August
September
October
November
December
TOTAL
2001
50% ($200)
$400 150
0
50
Unreimbursed child care expensesx
50% ($200)
50% ($200)
50% ($200)
100
0
June
March
May
AMOUNT
ORDERED
January
February
April
July
Year
AMOUNT
PAID
August
September
October
November
December
TOTAL
2001
50% ($200)
$237.50 0
0
0
Unreimbursed medical expensesx
50% ($200)
50% ($75)
0
Petitioner/Plaintiff
Defendant/Respondent
CASE NUMBER
Form MC-031
I request reimbursement for 50% of these expenses, which 
are supported by copies of bills, receipts, and other proof
of expense.
01/04/01
01/08/01
02/15/01
04/26/01
01/02
Dr. Adams
Dr. Lee, D.D.S.
02/02
03/02
04/02
$45.00
$155.00
AB X-ray Inc. $200.00
Exhibit A
Exhibit B
Exhibit C
Exhibit DKids Therapy $75.00
Child care expenses:
ABC School
ABC School
ABC School
ABC School
50% ($200)
50% ($200)
50% ($200)
50% ($200)
I declare under penalty of perjury under the laws of the State 
of California that the foregoing is true and correct.
Form MC-031 ATTACHED DECLARATION
(SIGNATURE OF DECLARANT)(TYPE OR PRINT NAME)
Exhibit E
. . . . . . . . . . . . . . . . . . . . . . . . . . .

Retrieval chunks

• #1

  Form ID: FL-421 Title: Payment History Attachment (Governmental—Uniform Parentage Act) Effective Date: 2003-07-01 Mandatory Form: no Info Page: https://selfhelp.courts.ca.gov/jcc-form/FL-421 Primary Download URL: https://www.courts.ca.gov/documents/fl421.pdf Form Detail Page: Payment History Attachment (Governm…

• #2

  100 0 100 Spousalx 100 You must complete a separate Payment History Attachment form for each type of unreimbursed expense. If you have more than one bill, receipt, and other proof of expense per month use an additional declaration page (form MC-031) or separate page. 1.) Itemize each expense; 2.) attach proof o…