Fill and Sign the California Stipulation Order Form

FL-625 GOVERNMENTAL AGENCY (pursuant to Welf. & Inst. Code, §§ 11475.1, 11478.2): TELEPHONE AND FAX NOS.: ––––– ––––– ––––– ––––– E -MAI L A DDRE SS ( O p t i o n a l): ––––– ATTORNEY FO R (N a m e ) : ––––– 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: ––––– STIPULATION AND ORDER 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) Loca l chi ld su p port ag e ncy (Family Cod e , §§ 1740 0 , 174 0 6 ) b y (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: $ ––––– p e r month; th e a greemen t is in t he b est interest o f the childre n ; t he n eeds of t he ch i ldren. will be met ad e quately b y the agreed amount ; the childre n are no t rece i ving pub l ic assistance; n o a p plication f o r pub l i c a s sistance i s p endi n g; an d a p plication o f the gui d elin e wo u ld be unju s t a n d inap p r o priate i n thi s case. We und e rstand that i f th e order i s b elow gui d elin e , no chang e o f circumst a nce s n e ed be s h own to raise t h is order to t he g uide l ine amount. If th e ord e r is above t he g uide l ine , a chan ge o f circ u m stances will be require d to m odif y this o r der. (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. Page one of three STIPULATION AND ORDER (Governmental) Family Code, §§ 17400, 17404, 17406Form Adopted by for Manditory Use Judicial Council of California FL- [Rev. July 1, 2005] elec troni c form ã 2004,5 WWW.LawCA.co m L a w P u b l i s h e r s PETITIONER/PLAINTIFF: ––––– ––––– RESPONDENT/DEFENDANT: ––––– ––––– OTHER PARENT: ––––– CASE NUMBER ––––– 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. d. Obligor shall pay current child support as follows: Name Date of birth Monthly support amount ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– (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. 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. Th e p a r e nts m u st notify t he l ocal c h ild support a gency i n writin g withi n 1 0 d a y s o f a ny chan g e i n resi d enc e or empl o y ment. 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. STIPULATION AND ORDER (Governmental) Page two of three FL-625 [Rev. July 1, 2005] elec troni c form ã 2004,5 WWW.LawCA.co m L a w P u b l i s h e r s PETITIONER/PLAINTIFF: ––––– ––––– RESPONDENT/DEFENDANT: ––––– ––––– OTHER PARENT: ––––– CASE NUMBER ––––– 3. k. T he fo l lowin g p e rso n (the “ o th e r pare n t” ) is add ed as a party t o this act i on under Family Code sect i on 1740 4 (name): ––––– l. Other (specify) : ––––– ––––– ––––– ––––– ––––– ––––– Date: ––––– ––––– (TYPE OR PRINT NAME) (SIGNATURE OF ATTORNEY for local child support agency) Date: ––––– ––––– (TYPE OR PRINT NAME) (SIGNATURE OF FATHER) Date: ––––– ––––– (TYPE OR PRINT NAME) (SIGNATURE OF ATTORNEY FOR FATHER) Date: ––––– ––––– (TYPE OR PRINT NAME) (SIGNATURE OF MOTHER) Date: ––––– ––––– (TYPE OR PRINT NAME) (SIGNATURE OF ATTORNEY FOR MOTHER) ORDER 4. The court so orders. Date: ––––– (JUDICIAL OFFICER) Signature follows last attachment 5. Number of pages attached: ––– STIPULATION AND ORDER (Governmental) Page three of three FL-625 [Rev. July 1, 2005] elec troni c form ã 2004,5 WWW.LawCA.co m L a w P u b l i s h e r s