Fill and Sign the Child Registry California Form

––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– –– –– –– –– ––––– ––––– –– –– –– ––––– –– –– –– ––––– –– ––––– –– –– –– ––––– –– ––––– –– –– –– ––––– –– –– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– –– FL-191 FOR COURT USE ONLY ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address) STAMP DATE RECEIVED HERE DO NOT FILE 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: CHILD SUPPORT CASE REGISTRY FORM CASE NUMBER Moth er Fath er First form completed Change to previous information THIS FORM WILL NOT BE FILED IN THE COURT FILE. IT WILL BE MAINTAINED IN A CONFIDENTIAL FILE WITH THE STATE OF CALIFORNIA. Notice: Pages 1 and 2 of this form must be completed and delivered to the court along with the court order for support. Pages 3 and 4 are instructional only and do not need to be delivered to the court. If you did not file the court order, you must complete this form and deliver it to the court within 10 days of the date on which you received a copy of the support order. Any later change to the information on this form must be delivered to the court on another form within 10 days of the change. It is important that you keep the court informed in writing of any changes of your address and telephone number. 1. Support order information (this information is on the court order you are filing, or have received). a. Date order filed: b . Initial child support or family support order Modificatio n c. Total monthly base current child or family support amount ordered for children listed below plus any monthly amount ordered payable on past due support (do not include child care, special needs, uninsured medical expenses, or travel for visitation): ( 1 ) Child support: $ Reserved order $0 (zero) order Past due child support: $ ( 2 ) Family support: $ Reserved order $0 (zero) order Past due family support: $ ( 3 ) Spousal support: $ Reserved order $0 (zero) order Past due spousal support: $ (4) Wage withholding was order ed ordered but stayed until 2. Person required to pay child or family support (name): Relationship to child (specify): 3. Person or agency to receive child or family support payments (name): Relationship to child (if applicable): 4. The child support order is for the following children: Child's name Date of birth Social security number a . b . C . d . e . Additional children are listed on a page attached to this document. TYPE OR PRINT IN INK Page 1 of4 Form Adopted for Mandatory Use Judicial Council of California FL-191 [Rev. Jiuy 1, 2005] CHILD SUPPORT CASE REGISTRY FORM Family Code, § 4014el ectr onic form ã 2005 WWW.LawCA.co m L a w P u b l i s h e r s ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– –– –– –– –– –– –– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– –– –– –– –– –– –– ––––– ––––– ––––– CASE NUMBERPETITIONER/PLAINTIFF : RESPONDENT/DEFENDANT : OTHER PARENT: You are required to complete the following information about yourself. You are not required to provide information about the other person, but you are encouraged to provide as much as you can. This form is confidential and will not be filed in the court file. It will be maintained in a confidential file with the State of California. 5. Father's name: 6. Mother's name: a. Date of birth: a. Date of birth: b. Social security number: b. Social security number: c. Street address: c. Street address: City, state, zip code: City, state, zip code: d. Mailing address: d. Mailing address: City, state, zip code: City, state, zip code: e. Driver's license number: e. Driver's license number: Stat e: Stat e: f. Telephone number: f. Telephone number: g . Employ ed Not employed Self- employed g . Employe d Not employed Self- employed Employer's name: Employer's name: Street address: Street address: City, state, zip code: City, state, zip code: Telephone number: Telephone number: 7 . A restraining order, protective order, or nondisclosure order due to domestic violence is in effect. a. The order protects: Fath er Moth er Childr en b. From: Fath er Moth er c. The restraining order expires (date): I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Dat e: (TYPE OR PRINT NAME) (SIGNATURE OF PERSON COMPLETING THIS FORM) FL-191 [Rev. July 1, 2005] CHILD SUPPORT CASE REGISTRY FORM Page 2 of 4el ectr onic form ã 2005 WWW.LawCA.co m L a w P u b l i s h e r s INFORMATION SHEET FOR CHILD SUPPORT CASE REGISTRY FORM (Do NOT deliver this Information Sheet to the court clerk.) Please follow these instructions to complete the Child Support Case Registry Form (form FL-191) if you do not have an attorney to represent you. Your attorney, if you have one, should complete this form. Both parents must complete a Child Support Case Registry Form. The information on this form will be included in a national database, which, among other things, is used to locate absent parents. When you file a court order, you must deliver a completed form to the court clerk along with your court order. If you did not file a court order, you must deliver a completed form to the court clerk WITHIN 10 DAYS of the date you received a copy of your court order. If any of the information you provide on this form changes, you must complete a new form and deliver it to the court clerk within 1 0 days of the change. The address of the court clerk is the same as the one shown for the superior court on your order. This form is confidential and will not be filed in the court file. It will be maintained in a confidential file with the State of California. INSTRUCTIONS FOR COMPLETING THE CHILD SUPPORT CASE REGISTRY FORM (TYPE OR PRINT IN INK): If the top section of the form has already been filled out, skip down to number 1 below. If the top section of the form is blank, you must provide this information. Front page. first box, top of form, left side: Print your name, address, telephone number, fax number, and e-mail address, if any, in this box. Attorneys must include their State Bar number. Front page, second box, left side: Print the name of the county and the court's address in this box. Use the same address for the court that is on the court order you are filing or have received. Front page, third box, left side: Print the names of the petitioner/plaintiff, respondent/defendant, and other parent in this box. Use the same names listed on the court order you are filing or have received. Front page. fourth box, left side: Check the box indicating whether you are the mother or the father. If you are the attorney for the mother, check the box for mother. If you are the attorney for the father, check the box for father. Also, if this is the first time you have filled out this form, check the box by ''First form completed.'' If you have filled out form FL-1 91 before, and you are changing any of the information, check the box by ''Change to previous information.'' Front page, first box, top of form, right side: Leave this box blank for the court's use. Front page, second box, right side: Print the court case number in this box. This number is also shown on the court papers. Instructions for numbered paragraphs: 1. a. Enter the date the court order was filed. This date is shown in the ''COURT PERSONNEL: STAMP DATE RECEIVED HERE'' box on the front page at the top of the order on the right side. If the order has not been filed, leave this item blank for the court clerk to fill in. order or family support order. Ifb. If the court order you filed or received is the first child or family support order for this case, check the box by ''Initial child support .. this is a change to your order, check the box by ''Modification.'' c. Information regarding the amount and type of support ordered and wage withholding is on the court order you are filing or have receive d. (1) Check this box if your order says that child support is ordered. If there is an amount, put it in the blank provided. If the order says the amount is reserved, check the ''Reserved order'' box. If the order says the amount is zero, check the '“$0 (zero) order'' box. Do not include child care, special needs, uninsured medical expenses, or travel for visitation. If the OrderlNotice to WIthhold Income for Child Support (form FL-195) says that there is a monthly amount payable on past due child support, check the box and enter the amount. (2) Check this box if your order says that family support is ordered. If there is an amount, put it in the blank provided. If the order says the amount is reserved, check the ''Reserved order'' box. If the order says the amount is zero, check the "$0 (zero) order'' box. Do not include child care, special needs, uninsured medical expenses, or travel for visitation. If the Order/Notice to Withhold Income for Child Support (form FL-195) says that there is a monthly amount payable on past due family support, check the box and enter the amount. FL-191 [Rev. July 1, 2005] CHILD SUPPORT CASE REGISTRY FORM Page 3 of 4el ectr onic form ã 2005 WWW.LawCA.co m L a w P u b l i s h e r s (3) Check the spousal support box only if a box is checked in Item 1 (c)(1) for child support. If it was, put the amount of spousal support in the blank provided. If the order says the amount is reserved, check the ''Reserved order'' box. If the order says the amount is zero, check the 10 (zero) order'' box. If the Order/Notice to Withhold Income for Child Support (form FL-1 95) says that there is a monthly amount payable on past due spousal support, check the box and enter the amount. (4) Check the ''ordered'' box if wage withholding was ordered with no conditions. Check the box ''ordered but stayed until'' if wage withholding was ordered but is not to be deducted until a later date. If the court delayed the effective date of the wage withholding enter the specific date. Check only one box in this item. 2. a. Write the name of the person who is supposed to pay child or family support. b. Write the relationship of that person to the child. 3. a. Write the name of the person or agency that is supposed to receive child or family support payments. b. Write the relationship of that person to the child. 4. List the full name, date of birth, and social security number for each child included in the support order. If there are more than five children included in the support order, check the box after item 4e and list the remaining children with dates of birth and social security numbers on another sheet of paper. Attach the other sheet to this form. The local child support agency is required, under section 466(a)(1 3) of the Social Security Act, to place in the records pertaining to child support, the social security number of any individual who is subject to a divorce decree, support order, or paternity determination or acknowledgment. This information is mandatory and will be kept on file at the local child support agency. Top of second page, box on left side: Print the names of the petitioner/plaintiff, respondent/defendant, and other parent in this box. Use the same names listed on the front page. Top of second page, box on right side: Print your court case number in this box. Use the same case number as on the front page, second box, right side. You are required to complete information about yourself. If you know information about the other person, you may also fill in what you know about him or her. 5. If you are the father in this case, list your full name in this space. See instructions for a-g under item 6 below. 6. If you are the mother in this case, list your full name in this space. a. List your date of birth. b. Write your social security number. c. List the street address, city, state, and zip code where you live. d. List the street address, city, state, and zip code where you want your mail sent, if different from the address where you live. e. Write your driver's license number and the state where it was issued. f. List the telephone number where you live. g. Indicate whether you are employed, self-employed, or not employed by checking the appropriate box. If you are employed, write the name, street address, city, state, zip code, and telephone number where you work. 7. If there is a restraining order, protective order, or nondisclosure order, check this box. a. Check the box beside each person who is protected by the restraining order. b. Check the box beside the parent who is restrained. c. Write the date the restraining order expires. See the restraining order, protective order, or nondisclosure order for this date. If you are in fear of domestic violence, you may want to ask the court for a restraining order, protective order, or nondisclosure order. You must type or print your name, fill in the date, and sign the Child Support Case Registry Form under penalty of perjury. When you sign under penalty of perjury, you are stating that the information you have provided is true and correct. FL-191 [Rev. July 1, 2005] CHILD SUPPORT CASE REGISTRY FORM Page 4 of 4el ectr onic form ã 2005 WWW.LawCA.co m L a w P u b l i s h e r s