FL-421 - Payment History Attachment - Instructions for Completing Payment Record

Sep 12, 2026

FL-421 Payment History Attachment provides a structured payment record for family law support and related expenses under the Family Law—Governmental—Uniform Parentage Act. The form instructs completing separate attachments for each type of support paid and each type of unreimbursed expense, listing yearly totals and month-by-month amounts ordered versus paid. It also requires attaching bills, receipts, and proof of expense in chronological order, and using exhibits for each bill or payment as needed.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Payment History for (check one)

Support types and monthly totals

Instructions for Completing Payment Record

Separate attachments and proof requirements

Unreimbursed child care, medical, or other expenses

Itemization and exhibits

| | | To keep other people from seeing what you entered on your form, please press the Clear This Form button at the end of the form when finished. | | FL-421 | | --- | --- | --- | --- | --- | | | PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT: | | CASE NUMBER: | | | OTHER PARENT: | | | | | PAYMENT HISTORY FOR (check one): Child Spousal Unreimbursed medical Family Medical Other (specify): Unreimbursed child care Year Year Year | | AMOUNT
ORDERED | AMOUNT
PAID | AMOUNT
ORDERED | AMOUNT
PAID | AMOUNT
ORDERED | AMOUNT
PAID | | --- | --- | --- | --- | --- | --- | --- | | January | | | | | | | | February | | | | | | | | March | | | | | | | | April | | | | | | | | May | | | | | | | | June | | | | | | | | July | | | | | | | | August | | | | | | | | September | | | | | | | | October | | | | | | | | November | | | | | | | | December | | | | | | | | TOTAL | | | | | | | Year Year Year | | AMOUNT
ORDERED | AMOUNT
PAID | AMOUNT
ORDERED | AMOUNT
PAID | AMOUNT
ORDERED | AMOUNT
PAID | | --- | --- | --- | --- | --- | --- | --- | | January | | | | | | | | February | | | | | | | | March | | | | | | | | April | | | | | | | | May | | | | | | | | June | | | | | | | | July | | | | | | | | August | | | | | | | | September | | | | | | | | October | | | | | | | | November | | | | | | | | December | | | | | | | | TOTAL | | | | | | | Page 1 of Form Approved for Optional Use Judicial Council of California FL-421 [Rev. July 1, 2003] PAYMENT HISTORY ATTACHMENT (Family Law—Governmental—Uniform Parentage Act) Family Code, §§ 5230.5, 17524 (a), 17526(c) [www.courtinfo.ca.gov](www.courtinfo.ca.gov) 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. | | AMOUNT
ORDERED | | AMOUNT
PAID | | AMOUNT
ORDERED | | AMOUNT
PAID | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | | January | 100 | | 0 | | 100 | | 100 | | | February | | | | | | | 0 | | | March | | | | | | | | | | April | | | 100 | | | | 100 | | | May | | | 100 | | | | 0 | | | June | | | 100 | | | | | | | July | | | 0 | | | | | | | August | | | | | | | 100 | | | September | | | | | | | 100 | | | October | | | 100 | | | | 0 | | | November | | | | | | | | | | December | | | | | | | | | | TOTAL | 1,200 | | 600 | | 1,200 | | 400 | | x Spousal | | AMOUNT
ORDERED | | AMOUNT
PAID | | | | --- | --- | --- | --- | --- | --- | | January | 100 | | 0 | | | | February | | | | | | | March | | | | | | | April | | | 100 | | | | May | | | 100 | | | | June | | | 100 | | | | July | | | 0 | | | | August | | | | | | | September | | | | | | | October | | | 100 | | | | November | | | | | | | December | | | | | | | TOTAL | 1,200 | | 600 | | | UNREIMBURSED CHILD CARE, MEDICAL, OR OTHER EXPENSES: 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

FAQs

When should a separate Payment History Attachment be completed for FL-421?

Complete a separate Payment History Attachment for each type of support paid and for each type of unreimbursed expense. Each attachment should include the applicable year and month-by-month amounts.

What information must be entered for each month on the payment record?

Enter the year, list the amount ordered, and the amount paid for each month during that year. Add amounts in each column to calculate yearly totals and enter totals at the bottom.

What proof must be attached for unreimbursed expenses?

Attach additional sheets and supporting documents such as bills, receipts, and other proof of expense as necessary. Itemize each expense, mark each bill or payment with an exhibit number, and group documents in chronological order for each month.

Sep 12, 2026

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