Fill and Sign the Attorney for Superior Court of California County of 490110213 Form

FL-420 ATTORNEY OR PARTY WITHOUT ATTORNEY Name and Address) or TELEPHONE NO.: GOVERNMENTAL AGENCY (under Family Code, §§ 17400, 17406): FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT: DECLARATION OF SUPPORT ARREARAGE CASE NUMBER: 1. The Obligor/Payor (person who pays support) is the Petitioner/Plaintiff Respondent/Defendant Other parent 2.The amount of support arrearages, interest, and penalties, if any, owed in this proceeding is calculated as follows:a. Tota l A m ount o f S upport$ as of (date): b. Am ou nt p aid$ as of (date): c. Amount applied to principal:$ d. Amount applied to interest:$ e. Balance of principal owed:$ as of (date): f. Balance of interest owed:*$ as of (date): g. Penalties ordered:*$ as of (date): h. Balance owed:$ as of (date): * If interest or penalties are not claimed, they are not waived.3. Details of the arrearage statement, consisting of (specify number): pages, are attached. 4. An interest calculation statement is attached.5. Other (specify): I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Declared on information and belief, D ate : (TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT) Form Adopted by for Manditory Use Judicial Council of Californiaf:-420 [Rev. January 1, 2003] DECLARATION OF SUPPORT ARREARAGE (Family Law) Family Code, §§ 5230.5, 7524(a), 17526(c) electronic form  2002 WWW.LawCA.com Law Publishers