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SCHD
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DISTRICT COURT
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CLARK COUNTY, NEVADA
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Plaintiff(s),
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CASE NO.
-vs-
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DEPT. NO.
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Defendant(s).
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SCHEDULE OF ARREARAGES
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STATE OF
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COUNTY OF
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)
)
)
ss:
, being first sworn, deposes and says:
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I am owed and entitled to receive certain periodic monthly payments from
pursuant to
filed with the Court on
is attached to this schedule.
. A copy of the relevant provision of that
has failed to make all of those payments
when due as set forth herein. The following schedule is a true and accurate statement
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of all payment due dates and of any payments received by me during the months noted.
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Further, affiant sayeth naught.
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I declare under penalty of perjury under the law of the State of Nevada that the
foregoing is true and correct.
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EXECUTED this
day of
, 20
.
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_____________________________________
Affiant
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DUE DATE SET
BY COURT DECREE
AMOUNT DUE THIS
PAYMENT
DATE PAYMENT
RECEIVED THIS MO.
AMOUNT OF
PAYMENT RECEIVED
TOTAL
ARREARAGES
THIS MONTH
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(PLEASE USE ADDITIONAL PAGES FOR ADDITIONAL ENTRIES)
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106756533/3/9/2016