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TELE P H O NE NO .: FAX N O.: SUP ER IO R C O URT O F C ALIF O RNIA , C O UNT Y O FFOR C O URT USE O NLY ST R EE T A D DR ESS : MAI LIN G AD DRESS : CIT Y A ND Z IP CO DE: BR AN C H NAM E: O THE R PAR ENT: NO TIC E R EG ARDIN G P A YM EN T O F S U PPO RTCASE N UM BE R: NO TIC E O F ASSIG NED S U PPO RT SU BSTIT UTIO N O F P A YEE 1. Th e obli go r ( th e ju dgm ent de bto r) in th is proc eedin g is (n am e an d la st k n ow n a d dr ess): 2 . The lo ca l chi ld su pport ag ency is pro vid in g se rv ic es in th is pr oc ee din g und er t it le IV -D of the S ocial S ecu rit y A ct.4 . The lo ca l chi ld su pport ag ency g iv e s n ot ic e th at5. NO TIC E OF A SSIG NM ENT : A n ass ignm ent o f s u pp ort rig hts by o p er ation of la w h as b een m ade to th e c ou nty n am ed a b ov e und er W elfa re an d I n stit u tio ns C ode s e ctio n 1 1477 (a ).  `          GO VER NM EN TA L AG EN CY ( u nde r Fam ily C ode , §§ 174 00, 1 74 06):F O R R EC O RDER ’S U SE ONLYFL -632REC O RDIN G REQ UES TED BY A N D WH EN REC ORDED MA IL TO :P E TITIO NER /PLA INTIFF :RES PO NDE NT/ DE FENDAN T:3 .T he lo ca l c hi ld s u pport ag ency is n o lo ng er pr ov idin g s e rv ic e s as fol lo w s:a . b.N o lo nger e nfo rc in g c u rr e nt s u ppo rt o nly — arr e ars w ill co nt in ue t o b e p aid to th e lo cal ch ild s up port a g en cy No lo nger pro vid ing an y s e rv ic e sa. b.th e g o ver nm ent al a ge ncy s p ecif ie d in th e top le ft bo x is su bstit ut ed as paye e. th e ju dgm ent d eb tor must m ak e all c u rre nt s u pport p aym ents in th is p ro ce ed in g to ( s p ecif y ):c.th e ju dgm ent d eb tor must m ak e all p aym en ts o n a rr ea ra ges in th is p ro ce e di ng to (1) th e paye e nam ed in it e m 4 b.(2)o th e r (s p e cif y):d .an abstr a ct of su pport ju dgm ent o r su pport ju dgm en t w as o rig in ally r e co rd ed in the c o un ty of (s p ecif y ):o n (da te) :at (R eco rd e r’s id en tif ic a tio n nu m be r) :T H E S U BS TIT U TE D P AY EE M UST BE C O NTA CT ED WHEN NOT IC E T O A LIE N HO LD ER MAY O R M UST BE G IV EN .For m A do pted fo r M an dato ry Use Judi cia l C ounc il of Cal if o rn iaNO TIC E R EG ARDING P A YM EN T O F S U PPO RT Pa ge 1 of 2 Family Code , §§ 42 00, 4 201 , 4204, 435 0, 4 3 51, 45 06.3 , 17 40 0 FL- 632 [Re v. July 1 , 20 05](G ove rn m en ta l)ele ctr o nic f o rm  2 005 WWW.LawCA.com La w P ublis h ers 7. a . b.    P E TI TIO NER /P LA INT IF F :CASE N UM BE R: RESPONDENT/DEFENDANT: OTH ER PARENT: 6 .N O TI CE O F S U PPO RT CO LLE C TI ON: F or p ur pos es o f c o lle c tio n on ly , th e g ove rn m enta l a gen cy id ent if ie d in th e to p lef t bo x is assig nee o f r e co rd o f a ll su p po rt o blig atio ns a s sp ecif ie d bel ow a nd tha t a genc y w il l a pp ear in th is c a se to e nfo rc ea. a ll s u pp ort ob lig atio ns.b. su pp ort a rre ars on ly . c. m ed ic al ob lig at ion s a s re quir e d by fe d era l la w . Each p are n t m us t n otif y the loca l c h ild s u pport ag ency in w rit in g wit h in 1 0 day s of any ch ange in r e sid ence or e m plo ym ent. Eac h p ar ent m ust c o m plete a C hild S up port C ase R egis tr y Fo rm ( F L-1 9 1) a n d file it w ith th e cou rt w it hi n 1 0 d ays of a ny cha nge in r e sid e nc e or e m plo ym ent.D ate :(T YP E OR PR INT NAME) (S IGN ATU RE) A CKNO W LED GM EN T (To b e co m ple ted on ly when th is f o rm i s r e co rd ed ) STA TE O F C ALIF O RNIA CO UNTY O FOn , b efo re me, No ta ry P ub lic , p er so na lly a ppea red :pers o n al ly kn o w n to m e (o r p ro ve d to m e on th e b asis o f s a tis fa ct ory evid ence ) to b e the pers o n(s ) w hose n am e(s ) is /a re su bsc ribe d to the w it hi n in str u m ent a nd a ckn ow le dg ed to me th at h e/s he /th ey e xe cu te d th e sa m e in h is /he r/th eir a uth oriz e d c a pacit y (ie s), a n d tha t b y his /h e r/th ei r sig na tu re( s) o n th e in str u m en t th e p ers o n(s ), o r th e e n tit y u pon beh alf of w hic h the pers on (s ) a cted , e xe cu te d th e in str u m en t.W IT N ESS m y ha nd a nd o ffic ia l s ea l.(S IGN ATUR E O F N O TA R Y)(S eal)FL- 632 [Re v. July 1 , 20 05]N O TIC E R EG AR D IN G P A YM ENT O F S U PPO RT (Gov ernm en ta l)Pa ge 2 of 2ele ctr o nic f o rm  2 005 WWW.LawCA.com La w P ublis h ers