FL 421 – Fill Out and Use This PDF

Updated: Nov 1, 2026

The FL-421 form is a critical document used in California's family court system to detail and attest to payment histories for various forms of support, including child, spousal, and unreimbursed medical or child care expenses. By systematically listing support ordered versus support paid on a monthly basis, this form serves as an essential tool for individuals to establish a clear, documented history of payments. Interested parties are encouraged to accurately complete the form, attaching additional documentation as necessary, to ensure a comprehensive representation of their financial contributions.

For detailed guidance on how to accurately fill out the FL-421 form and to ensure you're compliant with California's family law requirements, click the button below.

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FL 421 PDF Details

Managing financial responsibilities following a separation or divorce can often become complex, making it crucial for parties involved to maintain a detailed record of payments made or received. The FL-421 Payment History Attachment form serves as a vital tool in the California family law system, designed to streamline the process of recording and reporting various payments related to child support, spousal support, unreimbursed medical expenses, and childcare costs, among others. This form requires individuals to meticulously document the amount ordered by the court alongside the actual payments made for each month, ensuring clarity and transparency between parties and before the court. Whether it's for child or spousal support, or covering unreimbursed medical or childcare expenses, the FL-421 form aids in preventing disputes and misunderstandings by providing a structured format for presenting financial transactions. Its integral role in the family law proceedings underscores the importance of accurately completing and attaching relevant documentation, such as bills, receipts, and other proofs of expense, to support claims or statements made within the form. By requiring detailed itemization and chronological grouping of expenses and payments, the form not only facilitates ease of understanding but also aids in enforcing financial responsibilities as decreed by the court, promoting fairness and accountability in post-separation financial dealings.

Question	Answer
Form Name	Fl 421
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	what form 421, fl 421 california, how to form payment history, fl 421 form

How to Fill Out Form FL-421

Form FL-421 at a glance

What it is: Form FL-421 (Rev. July 1, 2003) is the Payment History Attachment (Family Law-Governmental-Uniform Parentage Act) of the Judicial Council of California.

What to bring and attach to Form FL-421

Attach additional sheets and supporting documents (bills, receipts, and other proof of expense) as necessary.

A filled-in Form FL-421 example: a parent lists a year of child support payments

Form FL-421 example filled out, example: a parent lists a year of child support payments — A parent lists child support payments on Form FL-421. The court ordered 100 a month in 2025, and the parent paid it every month except March. The picture shows page 1 only; every value in it is made up. JORDAN SAMPLE is the petitioner and CHRIS SAMPLE the respondent. The totals are 1,200 ordered and 1,100 paid. Nothing goes in OTHER PARENT because the case has no other parent.

How to fill out Form FL-421, box by box

Petitioner, respondent, other parent and case number

At the top, fill in PETITIONER/PLAINTIFF, RESPONDENT/DEFENDANT and OTHER PARENT, and the CASE NUMBER.

Payment history for (check one)

You must complete a separate Payment History Attachment form for each type of support paid.

Under PAYMENT HISTORY FOR (check one), check Child, Spousal, Family or Medical.

Year, amount ordered and amount paid

Enter the year, list the amount ordered, and the amount paid for each month during that year.

Under Year, enter the AMOUNT ORDERED and the AMOUNT PAID on the lines for January, February, March, April, May, June, July, August, September, October, November and December.

If the amounts repeat in a column, you can use an arrow.

Yearly totals

Add the amounts in each column to get the yearly totals, and enter the totals at the bottom.

Enter the TOTAL under AMOUNT ORDERED and AMOUNT PAID.

If your situation is different

Unreimbursed expenses

Check Unreimbursed child care, Unreimbursed medical or Other (specify).

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 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.

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.

Sources

[1] Form FL-421 (Rev. July 1, 2003), Payment History Attachment, Judicial Council of California (the Official source link on this page).