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                       FL-170ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address)FOR COURT USE ONLYTELEPHONE NO.F A X N O . ( O ptio nal) :E-MAIL ADDRESS (Optional):ATTORNEY FOR (Name) :SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS:MAILING ADDRESS:CITY AND ZIP CODE:BRANCH NAME: PETIT IO NER :RESPO NDEN T:DECLARATION FOR DEFAULT OR UNCONTESTEDCASE N UM BERDISSOLUTIONLEGAL SEPARATION(N O TE : I t e m s 1 t h ro ugh 1 6 a p ply t o b oth d is so lu tio n a n d l e g al s e p ara tio n p ro ceed in gs.) 1. I d ecla re t h at if I a ppeare d in c o urt a nd w ere s w orn , I w ould t e stif y t o t h e t r u th o f t h e f a cts in t h is d ecla ra tio n.2. I a gre e t h at m y c a se w ill b e p ro ve n b y t h is d ecla ra tio n a nd t h at I w ill n ot a ppear b efo re t h e c o urt u nle ss I a m o rd ere d b y t h e c o urt t od o s o .3 . A ll t h e in fo rm atio n in t h ePetitionR esp onse is t r u e a nd c o rre ct.4. Default or uncontested (Check a or b.)a.T he d efa ult o f t h e r e sp ondent w as e nte re d o r is b ein g r e queste d, a nd I a m n ot s e ekin g a ny r e lie f n ot r e queste d in t h e pe tit io n. O Rb.T he p artie s h ave a gre ed t h at t h e m atte r m ay p ro ce ed a s a n u nco nte ste d m atte r w it h out n otic e , a nd t h e a gre em ent isa tta ch ed o r is in co rp ora te d in t h e a tta ch ed s e ttle m ent a gre em ent o r s tip ula te d ju dgm ent.5. Settlement agreement (Check a or b.)a.T he p artie s h ave e nte re d in toa n a g re em en ta stipulated judgment regarding their propertyth eir m arria ge o r d om estic p artn ers h ip r ig hts , in clu din g s u pport, t h e o rig in al o f w hic h is o r h as b een s u bm it te d t o t h eco urt. I r e quest t h at t h e c o urt a ppro ve t h e a gre em ent.O Rb.T here i s n o a g re em en t o r s tip ula te d j u dgm en t, a nd t h e f o llo w in g s ta te m ents a re t r u e ( c h eck a t le ast o ne, inclu din g it e m ( 2 ) if a c o m munit y e sta te e xis ts ):(1 )(2 )T here a re n o c o m munit y o r q uasi- c o m munit y a sse ts o r c o m munit y d e bts t o b e d is p ose d o f b y t h e c o urt. Th e c o m munit y a nd q uasi- c o m munit y a sse ts a nd d ebts a re lis te d o n t h e a tta ch ed c o m ple te d c u rre nt P ro perty De cla ra tio n ( fo rm F L-1 60), w hic h in clu des a n e stim ate o f t h e v a lu e o f t h e a sse ts a nd d ebts t h at I p ro pose t o b e dis tr ib ute d t o e ach p arty . T he d iv is io n in t h e p ro pose d J u dgm ent ( F am ily L aw ) ( fo rm F L-1 8 0) is a f a ir a nd e qual div is io n o f t h e p ro p erty a nd d ebts , o r if t h ere is a n egativ e e sta te , t h e d ebts a re a ssig ned f a ir ly a nd e quit a bly .6 . D ecla ra tio n o f d is clo su re ( C he ck a , b , o r c .)a .B oth t h e p etit io ner a nd r e sp ondent h ave f ile d, o r a re f ilin g c o ncu rre ntly , a D ecla ra tio n R egard in g S erv ic e o f D ecla ra tio n of D is clo su re ( fo rm F L-1 41) a nd a n I n co m e a nd E xp ense D ecla ra tio n ( fo rm F L-1 5 0).b .T his m att e r is p ro ce edin g b y d efa ult . I a m t h e p etit io ner in t h is a ctio n a nd h ave f ile d a p ro of o f s e rv ic e o f t h e p re lim in ary De cla ra tio n o f D is clo su re ( fo rm F L-1 40) w it h t h e c o urt. I h ere by w aiv e r e ce ip t o f t h e f in al D ecla ra tio n o f D is clo su re ( fo rm FL -1 40) f r o m t h e r e sp ondent.c.T his m att e r is p ro ce edin g a s a n u nco nte ste d a ctio n. S erv ic e o f t h e f in a l D ecla ra tio n o f D is clo su re ( fo rm F L-1 40) is m utu ally wa iv e d b y b oth p a rtie s. A w aiv e r p ro vis io n e xe cu te d b y b oth p artie s u n der p enalt y o f p erju ry is c o nta in ed in t h e s e ttle m entagre em ent o r p ro pose d ju dgm ent o r a noth er, s e para te s tip ula tio n.7.8.C hild c u sto dy s h ould b e o rd ere d a s s e t f o rth in t h e p ro pose d J u dgm ent ( F am ily L aw ) ( fo rm F L-1 80). Ch ild v is it a tio n s h ould b e o rd ere d a s s e t f o rth in t h e p ro pose d J u dgm ent ( F am ily L aw ) ( fo rm F L-1 80).9 . S pousal, p artn er, a n d f a m ily s u pport ( If a s u pport o rd er o r a tto m ey f e es a re r e queste d, s u bm it a c o m ple te d I n co m e a ndE xp ense D ecla ra tio n ( fo rm F L-1 50 ) u nle ss a c u rre nt f o rm is o n f ile . I n clu de y o ur b est e stim ate o f t h e o th er p atty 's in co m e. Check a t le ast o ne o f t h e f o llo w in g.)a .b.c.d.I k n ow in gly g iv e u p f o re ve r a ny r ig ht t o r e ce iv e s p ousa l o r p artn er s u pport. I a sk t h e c o urt t o r e se rv e ju ris d ic tio n t o a w ard s p ousa l o r p artn er s u ppo rt in t h e f u tu re t o ( n am e): Sp ousa l s u pport s h ould b e o rd ere d a s s e t f o rth in t h e p ro pose d J u dg m ent ( F am ily L aw ) ( fo rm F L-1 80). Fa m ily s u pport s h ould b e o rd ere d a s s e t f o rth in t h e p ro pose d J u dgm ent ( F am ily L aw ) ( fo rm F L-1 80).P age 1 o f 2F orm A dopte d fo r M andato ry U se Ju dic ia l C ouncil o f C alif o rn ia FL-170 [Rev. January 1, 2007]DECLARATION FOR DEFAULT OR UNCONTESTED DISSOLUTION or LEGAL SEPARATION (Family Law)F am ily C ode, § 2 336,ele ctr o nic f o rm  2 005- 7 WWW.LawCA.com La w P ublis h ers                          P ETIT IO NER :CASE N UM BERR ESPO NDEN T:10.C hild s u pport s h o uld b e o rd ere d a s s e t f o rth in t h e p ro pose d J u dgm ent ( F am ily L aw ) ( fo rm F L-1 80).11. a. Iam r e ce iv in gam n o t r e ce iv in gin te nd t o a pply f o rpublic a ssis ta nce f o r t h e c h ild o r c h ild re n lis te din t h e p ro p ose d o rd er.b . T o t h e b est o f m y k n ow le dge, t h e o th er p artyisis not receiving public assistance.12.T he p etit io nerrespondent is presently receiving public assistance, and all support should be made payable to thelo ca l c h il d s u pport a gency a t t h e a dd re ss s e t f o rth in t h e p ro pose d ju dgm ent. A r e pre se nta tiv e o f t h e lo ca l c h ild s u pport a gency ha s s ig ne d t h e p ro pose d ju dgm ent.1 3. I f t h e re a re m in or c h ild re n, c h eck a nd c o m ple te it e m a a nd it e m b o r c - a. M y g ro ss ( b efo re t a xe s) m onth ly in co m e is ( s p ecif y ): $b .c.T he e stim ate d g ro ss m onth ly in co m e o f t h e o th er p arty is ( s p ecif y ): $ I h ave n o k n ow le dge o f t h e e stim ate d m onth ly in co m e o f t h e o th er p arty f o r t h e f o llo w in g r e aso ns ( s p ecif y ):d .I r e quest t h at t h is o rd er b e b ase d o n t h epetit io ner'srespondent's earning ability. The facts in support ofm y e stim ate o f e arn in g a bilit y a re ( s p ecif y ):C ontin ued o n A tta ch m ent 1 3d.14.P are n ta g e o f t h e c h ild re n o f t h e p etit io ner a nd r e sp ondent b orn p rio r t o t h eir m arria ge o r d om estic p artn ers h ip s h ould b e ord ere d a s s e t f o rth in t h e p ro pose d J u dgm ent ( F am ily L aw ) ( fo rm F L-1 8 0). A d ecla ra tio n r e gard in g p are nta ge is a tta ch ed.15.A tto rn ey f e es s h ould b e o rd ere d a s s e t f o rth in t h e p ro pose d J u dgm ent ( F am ily L aw ) ( fo rm F L-1 8 0).1 6.T he p etit io nerre sp ondentre quests r e sto ra tio n o f h is o r h er f o rm er n am e a s s e t f o rth in t h e p ro pose d J u dgm ent(F am ily L aw ) ( fo rm F L-1 80).1 7. T here a re ir re co ncila ble d if fe re nce s t h at h ave le d t o t h e ir re m edia ble b re akd ow n o f t h e m arria ge o r d om estic p artn ers h ip , a nd the re is n o p ossib ilit y o f s a vin g t h e m arria ge o r d om estic p artn ers h ip t h ro ugh c o unse lin g o r o th er m eans.1 8. T his d ecla ra tio n m ay b e r e vie w ed b y a c o m mis sio ner s if tin g a s a t e m pora ry ju dge, w ho m ay d ete rm in e w heth er t o g ra nt t h is re qu est o r r e quir e m y a ppeara nce u nder F am ily C ode s e ctio n 2 336.S TA TE M EN TS I N T H IS B O X A PPLY O NLY T O D IS SO LU TIO NS-it e m s 1 9 t h ro ugh 2 119. I f t h is is a d is s o lu tio n o f m arria ge o r o f a d om estic p artn ers h ip c re a te d in a noth er s ta te , t h e p etit io ner a nd/o r t h e r e sp ondenthas b een a r e sid e nt o f t h is c o unty f o r a t le ast t h re e m onth s a nd o f t h e s ta te o f C alif o rn ia f o r a t le ast s ix m onth s c o ntin uously an d im media te ly p re ce din g t h e d ate o f t h e f ilin g o f t h e p etit io n f o r d is so lu tio n o f m arria ge o r d om estic p artn ers h ip .20. I a sk t h at t h e c o urt g ra nt t h e r e q uest f o r a ju dgm ent f o r d is so lu tio n o f m arria ge o r d om estic p artn ers h ip b ase d u ponir re co ncila ble d if fe re nce s a nd t h at t h e c o urt m ake t h e o rd ers s e t f o rth in t h e p ro pose d J u dgm ent ( F am ily L aw ) ( fo rm F L-1 8 0) subm it te d w it h t h is d ecla ra tio n.21.T his d ecla ra tio n is f o r t h e t e rm in atio n o f m arit a l o r d om estic p artn er s ta tu s o nly . I a sk t h e c o urt t o r e se rv e ju ris d ic tio n ove r a ll is su es w hose d ete rm in atio n is n ot r e queste d in t h is d ecla ra tio n.THIS STATEMENT APPLIES ONLY TO LEGAL SEPARATIONS2 2. I a sk t h at t h e c o urt g ra nt t h e r e q uest f o r a ju dgm ent f o r le gal s e para tio n b ase d u pon ir re co ncila ble d if fe re nce s a nd t h at t h e court m ake t h e o rd ers s e t f o rth in t h e p ro pose d J u dgm ent ( F am ily L aw ) ( fo rm F L-1 80) s u bm it te d w it h t h is d ecla ra tio n.I understand that a judgment of legal separation does not terminate a marriage or domestic partnership and that I am still married or a partner in a domestic partnership.23.O th er ( s p ecif y ):I d ecla re u nder p e nalt y o f p erju ry u nder t h e la w s o f t h e S ta te o f C alif o rn ia t h at t h e f o re goin g is t r u e a nd c o rre ct.D ate :(T Y PE O R P R IN T N AM E)(S IG NATU RE O F D EC LA R AN T)FL-170 [Rev. January 1, 2007]DECLARATION FOR DEFAULT OR UNCONTESTED DISSOLUTION or LEGAL SEPARATION (Family Law)Page 2 o f 2

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