Fill and Sign the Fl 643 Form

FL-643 ATTORNEY OR PARTY WITHOUT ATTORNEY OR GOVERNMENTAL AGENCY (Name, State Bar number, and address): FOR COURT USE ONLY 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: CASE NUMBER:DECLARATION OF OBLIGOR'S INCOME DURING JUDGMENT PERIOD— PRESUMED INCOME SET–ASIDE REQUESTI, (name): declare that:1. I am the obligor (parent required to pay support). a representative of the local child support agency providing support services in this matter. other (specify): 2. On (date): a Judgment Regarding Parental Obligations (form FL-630) was entered using presumed income.3. Information concerning the obligor's income and other factors relevant to calculating the correct support for the time periods in the judgment follow: Obligor'sMonthlyTime Period% Of Time Guideline Source ofAverage With Children Support IncomeMonth/Year (start and end) Monthly Income (if known) Requested Informationa. $ $ b. $ $ c. $ $ d. $ $ e. $ $ f. $ $ g. $ $ h. $ $ i. $ $ 4. Additional evidence regarding the obligor's actual income is attached. (Black out your social security number from any papers, such as pay stubs, that you attach.) I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.Date: (TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT)Page 1 of 1Form Approved for Optional Use DECLARATION OF OBLIGOR'S INCOME DURING JUDGMENT PERIOD—Family Code, §§ 2330.1, 17400,Judicial Council of California 17428, 17430, 17432FL-643 [New January 1, 2007]PRESUMED INCOME SET–ASIDE REQUEST(Governmental) electronic form 2001-2007 WWW.LawCA.com Law Publishers