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ATTORNEY O R PA RTY WITHOUT ATTORNEY ( N am e, S tat e Ba r nu mbe r, a nd add ress) :FOR C O URT USE ONLY TEL EPHONE NO. : E-MAI L A D D R ES S (O pti ona l) : AT TO RN EY F O R (N am e): SU PER IO R C O UR T OF C A LI FO RNIA , C O UNTY O F STREE T AD DRES S: O TH ER P AR EN T: FIN DIN G S A ND R EC O M MEN DAT IO N O F C O M MIS SIO NERNam e (s p ecif y ): ob je cte d to Com mis sio ne r (n am e): he a ring th is m at te r as a te m pora ry ju dg e . TH IS M ATTE R P R O CEED ED AS F O LLO W S a. By c o urt h earin g, appear ance s a s fo llo w s:Lo ca l c hi ld s u pport ag ency at to rn ey (Fa mily Co de, § § 174 00, 17 406) by (n am e):b . ( Nam e of pare nt) : (N am e o f p a ren t) : are th e p are nts of th e ch ildr en li s te d bel ow . c. O blig or m ust p ay cu rre nt c h ild s u pp ort as fo llo w s:                  FL -6 65FA X NO . (O pti on al):M AIL IN G A D DR ES S:CIT Y AN D Z IP CO DE: BR AN C H N AM E: PE TI TIO NER /P LA IN TIF F: R ES PO NDEN T/D EFE NDAN T:CAS E NUM BE R :1 . 2.(1) (2) (3) (4)D ate : Dept.: Pet it io ne r/p la in tif f p re se nt Res ponden t/d efe nda nt p re se nt Oth e r p are nt p re se nt Ju dic ia l o ffic e r: Att o rn ey p re se n t (nam e): Att o rn ey p re se n t (nam e): Att o rn ey p re se n t (nam e): (5)b . (6) Oth e r ( s p e cif y): The o blig or ( th e p are nt o rd ere d to p ay s u pport) is the p et it io n er /p la in tif f res po nden t/d efe nda nt oth er p are nt.3 . 4.A tt a ch ed is a c om put er p rin to u t sh ow ing th e p are nts ’ inc om e a n d perc e nt age of tim e e ach p are nt s pe nds w it h th e c h ild (re n). The pr intou t, w hic h s ho ws th e c a lc u la tio n of c h ild s u pport pa ya ble , w ill b eco m e th e co urt’s fin di ngs. Thi s r e co m mended ord er is ba se d o n th e atta ch ed d ocu m ents (s p e cif y ):5 .T H E CO M MIS SIO NER R EC O M MEN DS T H E F O LLO W IN G a. A ll o rd ers prev iously m ade in th is a ctio n re m ain in f u ll fo rc e and ef fe ct exce pt as modif ie d be lo w.m oth er moth erfa th er fa th erN am e Date o f b ir th Month ly s u pp ort am ount(1 ) Oth e r (s p ecif y ):(2 )Fo r a tot al o f: $ begi nnin g (d ate ):p aya b le o n th e: da y of e ac h month( 3 ) The low-in co m e a dju stm en t a p pl ie s. The low-in co m e a dju stm en t d o es n ot a pply b eca use (s p e cif y r e aso ns):N O TIC E: An y part y r e qu ir e d to pa y ch il d sup port m ust pay in te re st o n ov erdu e am ount s a t t he le ga l r at e, w hic h is cur re nt ly 1 0 p erc en t p er y ear.F orm Ad opted for Al tern ative M an dato ry Use in ste ad o f F orm FL- 69 2 Jud ic ia l C ou ncil of Calif o rn ia FL-6 65 [Re v. July 1, 20 05]F IND IN G S A ND REC O M MEN DATIO N OF CO M MIS SIO NE R (Gove rn ment al) Pa ge 1 of 3 Fami ly C od e, § 42 51 ele ctr o nic f o rm  2 005 WWW.LawCA.com La w P ublis h ers P ET ITIO NER /P LAI NTIF F: CASE N UM BER : RES PO NDEN T/ DE FE N DAN T: OTHE R PARENT: 5 . c. d.A ny s u p po rt ord ere d wil l co ntin u e un til f u rthe r o rd er of c o ur t, un le ss t e rm inated by o p er ation of la w . Oblig or m ust pa y c h ild s up port fo r p as t perio ds a nd in th e am ounts s e t fo rth b e lo w: Nam e Dat e o f bir th Perio d of s u pport Am ount(1 ) Oth e r (s p e cif y):(3 ) In te re st a ccru es on th e e ntir e p rin cip al ba la nce o w ing and n ot o n e ach in sta ll me nt a s it b eco m es due . Oblig or o w es s u pport ar re ar s a s fo llo ws, a s of (d ate) :(2 ) In te re st is not inc luded a n d is not w aiv e d.P ayab le : $ beg in ni ng (d ate) : (4 ) In ter es t a ccru es o n th e e ntir e pr incip al b a la nce o w in g a n d n ot o n e ach in sta llm ent as it b ec om es du e. No p ro vis ion of th is ju d gm ent/o rd e r m ay o p e rat e to lim it a n y righ t to co lle ct th e p rin cip al (to tal a m oun t of u np aid su ppor t) or to cha rg e a n d c o lle ct in te re st a nd pe nalt ie s as a llo w ed by la w . A ll p ay ments or de re d are s u bj ect to m od ific a tio n. All p aym ents m ust b e m ade to (n am e a nd a d dr ess o f a ge ncy): O blig o r m us t p a y co sts of (sp eci fy): to (sp ecify):Th e c ou rt fu rth er r e co m men ds (s p ecif y ):                (4 )(2 )For a tot al of: $ pa yab le : $ on t h e: be gin nin g (d ate ):d ay of e ac h m on the .(1 )C hild s u pp ort: $ Spo u sa l s u p port: $ Family s u pp ort: $(3 )on t h e :da y of e a ch m ont hf. g.h.An Ord er/N otic e t o W it h hold In co m e f o r C hild S up port (fo rm F L-1 95 ) m us t i s su e.i.O blig or Obli ge emust ( 1) prov id e a nd m ainta in h ealth in su ra nc e co ve ra g e fo r t h e c h ild ren if it is a va il ab lej. k. l. t h ro u gh e m ploym ent o r a g rou p p la n, o r o th erw is e a va ila ble a t n o or re aso na bl e c o st, a nd m ust k e e p th e lo ca l ch ild s u pport age ncy in fo rm ed o f t h e a va il ab ilit y of the c o ve ra ge ; (2 ) if h ea lt h in su ra nce is n o t a va ila ble , p ro vid e c o ve ra ge w hen it be co m es a va il a ble ; (3 ) w it h in 2 0 d ays of th e loc al ch ild s up port a ge ncy r e q ue st, c o m plet e an d re tu rn a h ea lt h in su ra nce form ; ( 4 ) pro vid e to th e lo ca l c h ild s u ppor t a gency a ll in fo rm ation an d fo rm s neces sa ry to o bta in h e al th- ca re s e rv ic e s fo r t h e child re n; (5 ) p re se n t a n y c la im to s e cu re p aym en t o r r ei m bu rs em en t to th e o the r p ar en t o r c ar eta ke r w ho in cu rs co sts f o r he alth -c a re s e rv ic es fo r t h e c h ild re n; ( 6 ) a ssig n any r ig hts to r e im burs e m en t to th e o th e r par en t o r c a re ta ker w ho in cu rs co sts fo r h ea lt h c a re s e rv ic e s for the ch ild re n . If th e “ O blig or” box is c he cked , a h ealth in su ra nce co ve ra g e assig nm ent m ust iss ue . The par en ts m us t n otif y the loca l c hi ld s u pport a gency in writ ing wit h in 10 day s of a ny ch ange in r e side nce or e m ploy ment. The Notic e of R ig h ts a nd R es po nsib ili tie s an d I n fo rm ation She et o n C hang in g a C hil d Sup po rt O rd er ( fo rm FL -1 92 ) is atta ch ed. Th e fo ll o w in g p ers o n ( th e oth er p are nt) is a dded as a p arty to th is a ction under F am ily C ode s e ctio n 1 7404 (n am e): m.n .D ate :6. N um ber o f pa ges a tta ch ed: CO M MIS SI ONER SIGN ATU RE FO LLOW S LA ST ATTA CH ME NT FL -6 65 [ R ev. July 1, 2 005 ] FIN DING S A ND R EC O M MEN DATIO N O F C O M MIS SIO NER (G ov ern m en ta l)P ag e 2 o f 3e le ctr o nic f o rm  2 005 WWW.LawCA.com La w P ublis h ers Date : Cle rk , b y , Deput y      PETITIONE R/PLAINTIFF: CASE NUM BE R: RESPO NDENT/DEFENDANT: OTH ER P AR EN T: C LE RK ’S C ER TIF ICA TE O F M AIL IN G O R S ER VIC EI c e rtif y th at I a m no t a pa rty to th is ca us e and th at1 .P ers o nal s erv ic e . A tr ue cop y of this Fin d in gs a nd R eco m menda tio n o f C om mis sio ner w as ha nded to th e p etit io ne r/p lai ntif f re sp onde nt/d ef en dant at t h e h e ar ing of thi s m atte r b efo re th e c o m m ission er. o th e r p a re nt2.M ail. A tr u e c o py o f thi s Fi ndin gs a nd Re co m men da tio n o f C om missio ner wa s m ailed fir s t c la ss, p osta ge fu lly p re paid, in a se a le d en ve lo pe ad dre ss e d as s h o w n b el ow , a nd t h at t h e re ques t w as m aileda t (p la ce ): on (d ate ):C alif o rn ia ,FL- 665 [Re v. July 1, 2 005 ]FIN D IN G S A ND REC O M MEN DATIO N O F CO M MIS SIO NER (G overn m en ta l)P ag e 3 o f 3e le ctr o nic f o rm  2 005 WWW.LawCA.com La w P ublis h ers