Ariz. R. Fam. Law P. Form 5
Name: | __________________________ |
Mailing Address: | __________________________ |
City, State, Zip Code: | __________________________ |
Daytime Phone Number: | __________________________ |
Evening Phone Number: | __________________________ |
Representing: | [ ] Self [ ] Petitioner [ ] Respondent |
State Bar Number: | __________________________ |
ARIZONA SUPERIOR COURT, COUNTY OF _____ | |
__________________________ | Case No. |
__________________________ | |
Petitioner | |
ATLAS No. | |
__________________________ | |
__________________________ | |
Respondent | PROPOSED PATERNITY |
RESOLUTION STATEMENT OF: | |
[ ] FATHER | |
[ ] MOTHER | |
The undersigned party provides the following position on each of the issues in this case BE SPECIFIC. | ||
1. | IV-D Case: | |
[ ] | I receive or have received public assistance that may include AFDC, TANF, or AHCCCS for my children or me. | |
[ ] | I have a case with the Division of Child Support Services. | |
2. | Legal Decision-Making and Parenting Time: The other parent and I have the following natural or adopted children in common: | |
Child(ren)'s Name(s) | Date(s) of Birth | Age(s) |
__________________________ | __________________________ | __________________________ |
__________________________ | __________________________ | __________________________ |
__________________________ | __________________________ | __________________________ |
__________________________ | __________________________ | __________________________ |
The child(ren) should live primarily with [ ] Mother [ ] Father and have parenting time with [ ] Mother [ ] Father as follows (check all that apply): | ||
[ ] | In accordance with __________ County Guidelines for reasonable parenting time. | |
[ ] | Model Parenting Time Plans (describe plan). | |
[ ] | Every other weekend from: __________ at ___ a.m./p.m. to __________ at ___ a.m./p.m. | |
[ ] | One-half of the holidays on an alternating basis. | |
[ ] | For ___ weeks in the summer from __________ to __________ (inclusive). | |
[ ] | Spring Break from school. | |
[ ] | Other: | |
[ ] Mother or [ ] Father should have sole legal decision-making authority, | ||
OR | ||
[ ] Mother and Father should have joint legal decision-making authority. | ||
3. | Child Support: The financial factors necessary to calculate child support under the Arizona Child Support Guidelines are as follows (complete in full): | |
Father's gross monthly income: | $ __________ |
Mother's gross monthly income: | $ __________ |
[ ] | Father has ___ other child(ren) not listed above who live(s) in his household. |
[ ] | Father has ___ other child(ren) not listed above for whom he pays court-ordered child support in the amount of $ __________ per month. |
[ ] | Mother has ___ other child(ren) not listed above who live(s) in her household. |
[ ] | Mother has ___ other child(ren) not listed above for whom she pays court-ordered child support in the amount of $ __________ per month. |
[ ] | Medical insurance should be paid by [ ] Mother [ ] Father. Monthly cost for the child(ren) is $ __________. |
[ ] | Dental insurance should be paid by [ ] Mother [ ] Father. Monthly cost for the child(ren) is $ __________. |
[ ] | Vision insurance should be paid by [ ] Mother [ ] Father. Monthly cost for the child(ren) is $ __________. |
[ ] | Neither parent has insurance which is accessible and available at a reasonable cost. |
[ ] | Mother [ ] Father should pay cash medical support in the amount of $ __________ per month. |
[ ] | Monthly child care costs for ___ child[ren] is $ __________. |
[ ] | Extra education expenses or extraordinary child adjustments: I believe the court should add the following to the child support calculation (leave blank if none claimed): |
Description of expense | Monthly Amount |
$ | |
$ | |
$ |
[ ] | Uninsured medical/dental/vision expenses should be paid: | ||
[ ] | Pro rata based upon each party's income as provided in the Guidelines; or | ||
[ ] | Other: ___ % paid by Father and ___ % paid by Mother. | ||
[ ] | Tax Exemptions for the child(ren) should be divided (check one): | ||
[ ] | Pro rata based upon each party's income as provided in the Guidelines; or | ||
[ ] | Other: | ||
[ ] | Past support should be paid by [ ] Mother [ ] Father for the period of __________ through __________ in the amount of $ __________. | ||
[ ] | Direct payments for support have been [ ] received by me [ ] paid by me for the period of __________ through __________ in the amount of $ __________. | ||
[ ] | Past medical expenses have been incurred by me (and not reimbursed by insurance) for the period of __________ through __________ in the amount of $ __________ and the other parent should be ordered to reimburse me for ___ % of those expenses. | ||
[ ] | Expenses for pregnancy, childbirth, and genetic testing have been incurred by me (and not reimbursed by insurance) in the amount of $ __________ and the other parent should be ordered to reimburse me for ___ % of those expenses. | ||
4. | Attorneys' Fees: If the case is settled today, I want the court to order (choose one): | ||
[ ] | Each party to pay his or her own attorneys' fees and costs. | ||
[ ] | Mother to pay $ __________ of my attorneys' fees and costs within ___ days. | ||
[ ] | Father to pay $ __________ to other party for attorneys' fees and costs within ___ days. | ||
5. | Name Change: I want the child(ren)'s name(s) to be changed as follows: | ||
6. | Other Issues: Briefly state the other issues that you believe must be resolved to fully settle this case: | ||
7. | Settlement: I understand that I am required to personally meet and confer with the opposing party and their counsel at least five court days before my court date to resolve as many issues as possible unless there is a current court order prohibiting contact or a significant history of domestic violence between us. I verify that the above statements are true based on my best information and belief, and I am willing to settle and resolve this case based upon my positions as provided above. I will be prepared to show documentation to support my positions at the time of the conference or hearing. | ||
_____________________________________ | _____________________________________ |
Date |
Ariz. R. Fam. Law P. Form 5