Fill and Sign the Ca Modify Form

FL-350 ATTORNEY OR PARTY WITHOUT ATTORNEY TELEPHONE NO.: ––––– ––––– ––––– ––––– ––––– ATTORNEY FOR (Name) : ––––– FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF ––––– STREET ADDRESS: ––––– MAILING ADDRESS: ––––– CITY AND ZIP CODE: ––––– BRANCH NAME: ––––– PETITIONER/PLAINTIFF: ––––– ––––– RESPONDENT/DEFENDANT: ––––– STIPULATION TO ESTABLISH OR MODIFY CHILD SUPPORT AND ORDER CASE NUMBER: ––––– 1. a. Mother's net monthly disposable income: $ ––––– Father's net monthly disposable income: $ ––––– OR  b. A printout of a computer calculation of the parents' financial circumstances is attached. 2. Percentage of time each parent has primary responsibility for the children: Mother ––––– % Father ––––– % 3. a. A hardship is being experienced by the mother for: $ ––––– per month because of (specify) : ––––– The hardship will last until (date) : ––––– b. A hardship is being experienced by the father for: $ ––––– per month because of (specify) : ––––– The hardship will last until (date) : ––––– 4. The amount of child support payable by (name) : ––––– , referred to as the "obligor" below, as calculated under the guideline is: $ ––––– per month. 5. We agree to guideline support. 6. The guideline amount should be rebutted because of the following: a. We agree to child support in the amount of: $ ––––– per month; the agreement is in the best interest of the children; the needs of the children will be adequately met by the agreed amount; and application of the guideline would be unjust or inappropriate in this case. b. Other rebutting factors (specify) : ––––– 7. Obligor shall pay child support as follows beginning (date) : ––––– a. BASIC CHILD SUPPORT Child's name Monthly amount Payable to (name) ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– Total: $ ––––– payable on the first of the month other (specify) : ––––– b. In addition obligor shall pay the following: $ ––––– per month for child care costs to (name) : ––––– on (date) : ––––– $ ––––– per month for health care costs not deducted from gross income to (name) : ––––– on (date) : ––––– $ ––––– per month for special educational or other needs of the children to (name) : ––––– on (date) : ––––– other (specify) : ––––– c. Total monthly child support payable by obligor shall be: $ ––––– payable on the first of the month other (specify) : ––––– Form Adopted by for Manditory Use Judicial Council of California [Rev. July 1, 2003 STIPULATION TO ESTABLISH OR MODIFY CHILD SUPPORT AND ORDER Family Code, § 4065electronic form ã 2003 WWW.LawCA.com Law Publishers PETITIONER/PLAINTIFF: ––––– RESPONDENT/DEFENDANT: ––––– CASE NUMBER: ––––– 8. a. Health insurance shall be maintained by (specify name) : ––––– b. A health insurance coverage assignment shall issue if available through employment or other group plan or otherwise available at reasonable cost. Both parents are ordered to cooperate in the presentation, collection, and reimbursement of any medical claims. c. Any health expenses not paid by insurance shall be shared: Mother ––––– % Father ––––– % 9. a. A Wage and Earnings Assignment Order (form FL-195) shall issue. b. We agree that service of the wage assignment be stayed because we have made the following alternative arrangements to ensure payment (specify) : ––––– ––––– 10. Travel expenses for visitation shall be shared: Mother ––––– % Father ––––– % 11. We agree that we shall promptly inform each other of any change of residence or employment, including the employer’s name, address and telephone number. 12. Other (specify) : ––––– ––––– ––––– ––––– ––––– ––––– ––––– 13. We agree that we are fully informed of our rights under the California child support guidelines. 14. We make this agreement freely without coercion or duress. 15. The right to support a. has not been assigned to any county and no application for public assistance is pending. b. has been assigned or an application for public assistance is pending in (county name) : ––––– If you checked b., a district attorney of the county named must sign below, joining in this agreement. Date: ––––– ––––– (TYPE OR PRINT NAME) (SIGNATURE OF DISTRICT ATTORNEY) Notice: If the amount agreed to is less than the guideline amount, no change of circumstances need be shown to obtain a change in the support order to a higher amount. Date: ––––– ––––– (TYPE OR PRINT NAME) (SIGNATURE OF PETITIONER) Date: ––––– ––––– (TYPE OR PRINT NAME) (SIGNATURE OF RESPONDENT)) Date: ––––– ––––– (TYPE OR PRINT NAME) (SIGNATURE OF ATTORNEY FOR PETITIONER) Date: ––––– ––––– (TYPE OR PRINT NAME) (SIGNATURE OF ATTORNEY FOR RESPONDENT) THE COURT ORDERS 16. a. The guideline child support amount in item 4 is rebutted by the factors stated in item 6. b. Items 7 through 12 are ordered. All child support payments shall continue until further order of the court, or until the child marries, dies, is emancipated, or reaches age 18. The duty of support continues as to an unmarried child who has attained the age of 18 years, is a full-time high school student, and resides with a parent, until the time the child completes the 12th grade or attains the age of 19 years, whichever first occurs. Except as modified by this stipulation, all provisions of any previous orders made in this action shall remain in effect. Date: ––––– JUDGE OF THE SUPERIOR COURT NOTICE: Any party required to pay child support must pay interest on overdue amounts at the "legal" rate, which is currently 10 percent. This can be a large added amount. [Rev. July 1, 2003 STIPULATION TO ESTABLISH OR MODIFY CHILD SUPPORT AND ORDER Page 2 of 2electronic form ã 2003 WWW.LawCA.co m Law Publishers