California Stipulation Order

STIPULATION AND ORDER (Governmental)

GOVERNMENTAL AGENCY (pursuant to Welf. & Inst. Code, §§ 11475.1, 11478.2):   TELEPHONE AND FAX NOS.:

E-MAIL ADDRESS (Optional):   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:

OTHER PARENT:

CASE NUMBER:

1. THIS MATTER PROCEEDED AS FOLLOWS:

a. By written stipulation without court appearance.

b. By court hearing, appearances as follows:

(1) Date: Dept.: Judicial officer:

(2) Petitioner/Plaintiff present Attorney present (name):

(3) Respondent/Defendant present Attorney present (name):

(4) Other parent present Attorney present (name):

(5) Local child support agency (Family Code, §§ 17400, 17406) by (name):

(6) Other (specify):

c. The Obligor (the parent ordered to pay support) is Petitioner/Plaintiff Respondent/Defendant Other parent

2. This order is based on the attached documents (specify):

3. THE PARTIES AGREE THAT

a. All orders previously made in this action shall remain in full force and effect except as specifically modified below.

b. The amount of support payable by obligor as calculated under the guideline is: $ per month.

We agree to guideline support.

The guideline amount should be rebutted because of the following:

(1) We have been fully informed of the guideline amount of support; we agree voluntarily to child support of: $ per month.

The agreement is in the best interest of the children.

(2) Other rebutting factors (specify):

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.

3. c. Attached is a computer printout showing the parent's income and percentage of time each parent spends with the child(ren).

The printout, which shows the calculation of child support payable, shall become the court's findings.

3. d. Obligor shall pay current child support as follows:

Current child support table

Name      Date of birth      Monthly support amount

Child 1: $

Child 2: $

Child 3: $

(1) Other (specify):

(2) For a total of: $ payable on the: day of each month beginning (date):

(3) The support order was reduced, pursuant to the low-income adjustment, because the Obligor's net monthly income is less than $1,000.

(4) Any support ordered shall continue until further order of court, unless terminated by operation of law.

3. e. Obligor owes child support arrears as follows, as of (date):

(1) Child support: $ Spousal support: $ Family support: $

(2) Interest is not included and is not waived.

(3) Payable: $ on the day of each month beginning (date):

(4) Interest shall accrue on the entire principal balance owing and not on each installment as it becomes due.

f. No provision of this judgment shall operate to limit any right to collect the principal (total amount of unpaid support) or to charge and collect interest and penalties as allowed by law. All payments ordered are subject to modification.

g. All payments shall be made to (name and address of agency):

h. An Order/Notice to Withhold Income for Child Support (form FL-195) will issue.

i. Obligor/Obligee shall (1) provide and maintain health insurance coverage for the children if it is available through employment, a group plan, or otherwise available at no or reasonable cost, and shall keep the district attorney's office informed of the availability of the coverage; (2) if health insurance is not available, provide coverage when it becomes available; (3) within 20 days of the district attorney's request, complete and return a health insurance form; (4) provide to the district attorney all information and forms necessary to obtain health care services for the children; (5) present any claim to secure payment or reimbursement to the other parent or caretaker who incurs costs for health care services to the children; (6) assign any rights to reimbursement to the other parent or caretaker who incurs costs for health care services for the children.

If the "obligor" box is checked, a Health Insurance Coverage Assignment shall issue.

j. The parents must notify the local child support agency in writing within 10 days of any change in residence or employment.

k. The Notice of Rights and Responsibilities—Health-Care Costs and Reimbursement Procedures and Information Sheet on Changing a Child Support Order (form FL-192) is attached.

3. k. The following person (the "other parent") is added as a party to this action under Family Code section 17404 (name):

3. l. Other (specify):

ORDER

4. The court so orders.

Date: (JUDICIAL OFFICER)

Signature follows last attachment

5. Number of pages attached:

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