Fill and Sign the Ca Income Form 497299002

FL-643 ATTORNEY OR PARTY WITHOUT ATTORNEY OR GOVERNMENTAL AGENCY (Name, State Bar number, and address): FOR COURT USE ONLY ––––– ––––– ––––– ––––– TELEPHONE NO.: ––––– FAX NO. (Optional): ––––– E-MAIL ADDRESS (Optional): ––––– ATTORNEY FOR (Name) ––––– SUPERIOR COURT OF CALIFORNIA, COUNTY OF ––––– STREET ADDRESS: ––––– MAILING ADDRESS: ––––– CITY AND ZIP CODE: ––––– BRANCH NAME: ––––– PETITIONER/PLAINTIFF: ––––– RESPONDENT/DEFENDANT: ––––– OTHER PARENT: ––––– CASE NUMBER: DECLARATION OF OBLIGOR'S INCOME DURING JUDGMENT PERIOD— ––––– PRESUMED INCOME SET–ASIDE REQUEST I, (name): ––––– declare that: 1. I am the obligor (parent required to pay support). a representative of the local child support agency providing support services in this matter. other (specify): ––––– 2. On (date): ––––– a Judgment Regarding Parental Obligations (form FL-630) was entered using presumed income. 3. Information concerning the obligor's income and other factors relevant to calculating the correct support for the time periods in the judgment follow: Obligor's Monthly Time Period % Of Time Guideline Source of Average With Children Support Income Month/Year (start and end) Monthly Income (if known) Requested Information a. ––––– $ ––––– $ ––––– ––––– ––––– b. ––––– $ ––––– $ ––––– ––––– ––––– c. ––––– $ ––––– $ ––––– ––––– ––––– d. ––––– $ ––––– $ ––––– ––––– ––––– e. ––––– $ ––––– $ ––––– ––––– ––––– f. ––––– $ ––––– $ ––––– ––––– ––––– g. ––––– $ ––––– $ ––––– ––––– ––––– h. ––––– $ ––––– $ ––––– ––––– ––––– i. ––––– $ ––––– $ ––––– ––––– ––––– 4. Additional evidence regarding the obligor's actual income is attached. (Black out your social security number from any papers, such as pay stubs, that you attach.) I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: ––––– ––––– (TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT) Page 1 of 1 Form Approved for Optional Use DECLARATION OF OBLIGOR'S INCOME DURING JUDGMENT PERIOD— Family Code, §§ 2330.1, 17400, Judicial Council of California 17428, 17430, 17432 FL-643 [New January 1, 2007] PRESUMED INCOME SET–ASIDE REQUEST (Governmental) electronic form ã 2001- 2007 WWW.LawCA.com Law Publishers