Fill and Sign the Fl191 Fl 191 Attorney or Party Without Attorney Form

                              FL-191FOR COURT USE ONLYATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address)STA M P D ATE R EC EIV ED H ER ED O N O T F IL ETELEPHONE NO.F A X N O . ( O ptio nal) :E-MAIL ADDRESS (Optional):ATTORNEY FOR (Name) :SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS:MAILING ADDRESS:CITY AND ZIP CODE:BRANCH NAME: PETIT IO NER /P LA IN TIF F:R ESPO NDEN T/D EFE N DAN T:O TH ER P AR EN T:C HIL D S U PPO RT C ASE R EG IS TR Y F O RMCASE N UM BERM oth erF ath erF ir s t f o rm c o m ple te d Change t o p re vio u s in fo rm atio n T H IS F O RM W IL L N O T B E F IL E D IN T H E C O URT F IL E . IT W IL L B E MAIN TA IN ED IN A C O NFID EN TIA L F IL E W IT H T H E S TA TE O F C ALIF O RNIA . Notic e: P ag es 1 a n d 2 o f t h is f o rm m ust b e c o m ple te d a n d d eliv ere d t o t h e c o urt a lo ng w it h t h e c o urt o rd er f o r s u pport. Pa g es 3 a n d 4 a re i n str u ctio nal o nly a n d d o n ot n eed t o b e d eliv ere d t o t h e c o urt. I f y o u d id n ot f ile t h e c o urt o rd er, y o u m ust co m ple te t h is f o rm a n d d eliv er i t t o t h e c o urt w it h in 1 0 d ays o f t h e d ate o n w hic h y o u r e ceiv ed a c o py o f t h e s u pport o rd er. An y l a te r c h an ge t o t h e i n fo rm atio n o n t h is f o rm m ust b e d eliv ere d t o t h e c o urt o n a n oth er f o rm w it h in 1 0 d ays o f t h e chan ge. I t i s i m porta n t t h at y o u k e ep t h e c o urt i n fo rm ed i n w rit in g o f a n y c h an ges o f y o ur a d dre ss a n d t e le p hone n um ber.1 . S upport o rd er in fo rm atio n ( th is in fo rm atio n is o n t h e c o urt o rd er y o u a re f ilin g, o r h ave r e ce iv e d). a. D ate o rd er f ile d:b.In it ia l c h ild s u ppo rt o r f a m ily s u pport o rd erM odif ic a tio nc. T ota l m onth ly b a se c u rre nt c h ild o r f a m ily s u pport a m ount o rd ere d f o r c h ild re n lis te d b elo w p lu s a ny m onth ly a m ount o rd ere d paya ble o n p a st d ue s u pport ( d o n ot in clu de c h ild c a re , s p ecia l n eeds, u nin su re d m edic a l e xp ense s, o r t r a ve l f o r v is it a tio n):(1 )C hild s u p port:$R ese rv e d o rd er$0 ( z e ro ) o rd erPast due child support: $(2 )Family support: $Rese rv e d o rd er$0 ( z e ro ) o rd erPast due family support: $(3 )S pousa l s u pport: $R ese rv e d o rd er$0 ( z e ro ) o rd erP ast d ue s p ousa l s u pport: $(4) Wage withholding wasord ere dord ere d b ut s ta ye d u ntil2 . P ers o n r e quir e d t o p ay c h ild o r f a m ily s u pport ( n am e):R ela tio nsh ip t o c h ild ( s p ecif y ):3 . P ers o n o r a gen cy t o r e ce iv e c h ild o r f a m ily s u pport p aym ents ( n am e): Re la tio nsh ip t o c h ild ( if a pplic a ble ):4 . T he c h ild s u pp ort o rd er is f o r t h e f o llo w in g c h ild re n: Child 's n am eDate o f b ir thS ocia l s e cu rit y n um bera.b.C.d.e.A ddit io nal c h ild re n a re lis te d o n a p a ge a tta ch ed t o t h is d ocu m ent.TYPE OR PRINT IN INKPage 1 of4Form A dopte d fo r M andato ry U se Ju dic ia l C ouncil o f C alif o rn ia FL -1 91 [R ev. J iu y 1 , 2 005]CHILD SUPPORT CASE REGISTRY FORMFam ily C ode, § 4 014ele ctr o nic f o rm  2 005 WWW.LawCA.com La w P ublis h ers               CASE N UM BERP ETIT IO NER /P LA IN TIF F:R ESPO NDEN T/D EFE N DAN T:O TH ER P AR EN T:Y ou a re r e quir e d t o c o m ple te t h e f o llo w in g in fo rm atio n a bout y o urs e lf . Y ou a re n ot r e quir e d t o p ro vid e in fo rm atio n a bout t h e o th er pers o n, b u t y o u a re e nco ura ged t o p ro vid e a s m uch a s y o u c a n. T his f o rm is c o nfid entia l a nd w ill n ot b e f ile d in t h e c o urt f ile . I t w ill b e main ta in ed in a c o nfid entia l f ile w it h t h e S ta te o f C alif o rn ia .5. F ath er's n am e:6. M oth er's n am e:a. D ate o f b ir th :a. D ate o f b ir th :b. S ocia l s e cu rit y n um ber:b . S ocia l s e cu rit y n um ber:c . S tr e et a ddre ss:c. S tr e et a ddre ss:C it y , s ta te , z ip c o de:C it y , s ta te , z ip c o de:d. M ailin g a ddre ss:d . M ailin g a ddre ss:C it y , s ta te , z ip c o de:C it y , s ta te , z ip c o de:e. D riv e r's lic e nse n um ber:e . D riv e r's lic e nse n um ber:S ta te :S ta te :f. T ele phone n um ber:f. T ele phone n um ber:g .E m plo ye dN ot e m plo ye dS elf - e m plo ye dg.E m plo ye dN ot e m plo ye dS elf - e m plo ye dE m plo ye r's n am e:E m plo ye r's n am e:S tr e et a d dre ss:S tr e et a d dre ss:C it y , s ta te , z ip c o de:C it y , s ta te , z ip c o de:T ele phone n um ber:T ele phone n um ber:7 .A r e str a in in g o rd e r, p ro te ctiv e o rd er, o r n ondis clo su re o rd er d ue t o d om estic v io le nce is in e ffe ct.a . T he o rd er p ro te cts :F ath erM oth erC hild re nb. F ro m :Fath erM oth erc. T he r e str a in in g o rd er e xp ir e s ( d ate ):I d ecla re u nder p e nalt y o f p erju ry u nder t h e la w s o f t h e S ta te o f C alif o rn ia t h at t h e f o re goin g is t r u e a nd c o rre ct.D ate :(T Y PE O R P R IN T N AM E)(S IG NATU RE O F P ER SO N C O M PLE TIN G T H IS F O RM )FL-1 91 [R ev. J u ly 1 , 2 005]CHILD SUPPORT CASE REGISTRY FORMPage 2 of 4ele ctr o nic f o rm  2 005 WWW.LawCA.com La w P ublis h ers IN FO RM ATIO N S H EET F O R C HIL D S U PPO RT C A SE R EG IS TR Y F O RM (Do N O T d eliv e r t h is I n fo rm atio n S heet t o t h e c o urt c le rk .)P le ase f o llo w t h ese in str u ctio ns t o c o m ple te t h e C hild S upport C ase R egis tr y F orm ( fo rm F L-1 91) if y o u d o n ot h ave a n a tto rn ey t o re pre se nt y o u. Y ou r a tto rn ey, if y o u h ave o ne, s h ould c o m ple te t h is f o rm .Both p are nts m ust c o m ple te a C hild S upport C ase R egis tr y F orm . T he in fo rm atio n o n t h is f o rm w ill b e in clu ded in a n atio nal d ata base , whic h , a m ong o th er t h in gs, is u se d t o lo ca te a bse nt p are nts . W hen y o u f ile a c o urt o rd er, y o u m ust d eliv e r a c o m ple te d f o rm t o t h e court c le rk a lo ng w it h y o ur c o urt o rd er. I f y o u d id n ot f ile a c o urt o rd er, y o u m ust d eliv e r a c o m ple te d f o rm t o t h e c o urt c le rk W IT H IN 1 0 DA YS o f t h e d ate y o u r e ce iv e d a c o py o f y o ur c o urt o rd er. I f a ny o f t h e in fo rm atio n y o u p ro vid e o n t h is f o rm c h anges, y o u m ust co m ple te a n ew f o rm a nd d eliv e r it t o t h e c o urt c le rk w it h in 1 0 d ays o f t h e c h ange. T he a ddre ss o f t h e c o urt c le rk is t h e s a m e a s t h e one s h ow n f o r t h e s u perio r c o urt o n y o ur o rd er. T his f o rm is c o nfid en tia l a nd w ill n ot b e f ile d in t h e c o urt f ile . I t w ill b e m ain ta in ed in a co nfid entia l f ile w it h t h e S ta te o f C alif o rn ia .IN STR UCTIO NS F O R C O M PLE TIN G T H E C HIL D S U PPO RT C ASE R EG IS TR Y F O RM ( T Y PE O R P R IN T I N I N K):If t h e t o p s e ctio n o f t h e f o rm h as a lr e ady b een f ille d o ut, s kip d ow n t o n um ber 1 b elo w . I f t h e t o p s e ctio n o f t h e f o rm is b la nk, y o u must p ro vid e t h is in fo rm atio n.F ro nt p age. f ir s t b ox, t o p o f f o rm , le ft s id e: P rin t y o ur n am e, a ddre ss, t e le phone n um ber, f a x n um ber, a nd e -m ail a ddre ss, if a ny, in t h is b ox. A tto rn eys m ust in clu de t h eir S ta te B ar n um ber. F ro nt p age, s e co nd b ox, le ft s id e: P rin t t h e n am e o f t h e c o unty a nd t h e c o urt's a ddre ss in t h is b ox. U se t h e s a m e a ddre ss f o r t h e c o urt th at is o n t h e c o urt o rd er y o u a re f ilin g o r h ave r e ce iv e d. F ro nt p age, t h ir d b ox, le ft s id e: P rin t t h e n am es o f t h e p etit io ner/p la in tif f, r e sp ondent/d efe ndant, a nd o th er p are nt in t h is b ox. U se t h e sa m e n am es lis te d o n t h e c o urt o rd er y o u a re f ilin g o r h ave r e ce iv e d. F ro nt p age. f o urth b ox, le ft s id e: C heck t h e b ox in dic a tin g w heth er y o u a re t h e m oth er o r t h e f a th er. I f y o u a re t h e a tto rn ey f o r t h e m oth er, c h eck t h e b ox f o r m oth er. I f y o u a re t h e a tto rn ey f o r t h e f a th er, c h eck t h e b ox f o r f a th er. A ls o , if t h is is t h e f ir s t t im e y o u h ave fille d o ut t h is f o rm , c h eck t h e b ox b y ''F ir s t f o rm c o m ple te d.'' I f y o u h ave f ille d o ut f o rm F L-1 9 1 b efo re , a nd y o u a re c h angin g a ny o f t h e info rm atio n, c h eck t h e b ox b y ''C han ge t o p re vio us in fo rm atio n.''F ro nt p age, f ir s t b ox, t o p o f f o rm , r ig ht s id e: L eave t h is b ox b la nk f o r t h e c o urt's u se .F ro nt p age, s e co nd b ox, r ig ht s id e: P rin t t h e c o urt c a se n um ber in t h is b ox. T his n um ber is a ls o s h ow n o n t h e c o urt p apers .In str u ctio ns f o r n um bere d p ara g ra p hs:1. a . E nte r t h e d ate t h e c o urt o rd er w as f ile d. T his d ate is s h ow n in t h e ''C O URT P ER SO NNEL: S TA M P D ATE R EC EIV ED H ER E'' b oxon t h e f r o nt p age a t t h e t o p o f t h e o rd er o n t h e r ig ht s id e. I f t h e o rd er h a s n ot b een f ile d, le ave t h is it e m b la nk f o r t h e c o urt c le rk t ofill in .ord er o r f a m ily s u pport o rd er. I fb . I f t h e c o urt o rd er y o u f ile d o r r e ce iv e d is t h e f ir s t c h ild o r f a m ily s u pport o rd er f o r t h is c a se , c h eck t h e b ox b y ''I n it ia l c h ild s u pport .. t h is is a c h ange t o y o ur o rd er, c h eck t h e b ox b y ''M odif ic a tio n.''c . I n fo rm atio n r e g ard in g t h e a m ount a nd t y p e o f s u pport o rd ere d a nd w age w it h hold in g is o n t h e c o urt o rd er y o u a re f ilin g o r h avere ce iv e d.(1 ) C heck t h is b ox if y o ur o rd er s a ys t h at c h ild s u pport is o rd ere d. I f t h ere is a n a m ount, p ut it in t h e b la nk p ro vid ed. I f t h e o rd er says t h e a m ou nt is r e se rv e d, c h eck t h e ''R ese rv e d o rd er'' b ox. I f t h e o rd er s a ys t h e a m ount is z e ro , c h eck t h e '“ $ 0 ( z e ro ) ord er'' b ox. D o n ot in clu de c h ild c a re , s p ecia l n eeds, u nin su re d m edic a l e xp ense s, o r t r a ve l f o r v is it a tio n. I f t h e O rd erlN otic e to W Ith hold I n co m e f o r C hild S upport ( fo rm F L-1 95) s a ys t h at t h ere is a m onth ly a m ount p aya ble o n p ast d ue c h ild s u pport, ch eck t h e b ox a nd e nte r t h e a m ount.( 2 ) C heck t h is b ox if y o ur o rd er s a ys t h at f a m ily s u pport is o rd ere d. I f t h ere is a n a m ount, p ut it in t h e b la nk p ro vid ed. I f t h e o rd er says t h e a m ou nt is r e se rv e d, c h eck t h e ''R ese rv e d o rd er'' b ox. I f t h e o rd er s a ys t h e a m ount is z e ro , c h eck t h e " $ 0 ( z e ro ) ord er'' b ox. D o n ot in clu de c h ild c a re , s p ecia l n eeds, u nin su re d m edic a l e xp ense s, o r t r a ve l f o r v is it a tio n. I f t h e O rd er/N otic e to W it h hold I n co m e f o r C hild S upport ( fo rm F L-1 95) s a ys t h at t h e re is a m onth ly a m ount p aya ble o n p ast d ue f a m ily s u pport, ch eck t h e b ox a nd e nte r t h e a m ount.F L-1 91 [R ev. J u ly 1 , 2 005]CHILD SUPPORT CASE REGISTRY FORMPage 3 o f 4e le ctr o nic f o rm  2 005 WWW.LawCA.com La w P ublis h ers (3 ) C heck t h e s p ou sa l s u pport b ox o nly if a b ox is c h ecke d in I te m 1 ( c )(1 ) f o r c h ild s u pport. I f it w as, p ut t h e a m ount o f s p ousa lsu pport in t h e b la nk p ro vid ed. I f t h e o rd er s a ys t h e a m ount is r e se rv e d, c h eck t h e ''R ese rv e d o rd er'' b ox. I f t h e o rd er s a ys t h e am ount is z e ro , c h eck t h e 1 0 ( z e ro ) o rd er'' b ox. I f t h e O rd er/N otic e t o W it h hold I n co m e f o r C hild S upport ( fo rm F L-1 9 5) s a ys th at t h ere is a m onth ly a m ount p aya ble o n p ast d ue s p ousa l s u pport, c h eck t h e b ox a nd e nte r t h e a m ount.( 4 ) C heck t h e ''o rd e re d'' b ox if w age w it h hold in g w as o rd ere d w it h n o c o ndit io ns. C heck t h e b ox ''o rd ere d b ut s ta ye d u ntil'' if w agew it h hold in g w as o rd ere d b ut is n ot t o b e d educte d u ntil a la te r d ate . I f t h e c o urt d ela ye d t h e e ffe ctiv e d ate o f t h e w age wit h hold in g e nte r t h e s p ecif ic d ate . C heck o nly o ne b ox in t h is it e m .2. a . W rit e t h e n a m e o f t h e p ers o n w ho is s u ppose d t o p ay c h ild o r f a m ily s u pport. b. W rit e t h e r e la tio nsh ip o f t h at p ers o n t o t h e c h ild .3. a . W rit e t h e n a m e o f t h e p ers o n o r a gency t h at is s u ppose d t o r e ce iv e c h ild o r f a m ily s u pport p aym ents . b. W rit e t h e r e la tio nsh ip o f t h at p ers o n t o t h e c h ild .4. L is t t h e f u ll n am e, d ate o f b ir th , a n d s o cia l s e cu rit y n um ber f o r e ach c h ild in clu ded in t h e s u pport o rd er. I f t h ere a re m ore t h an f iv e ch ild re n in clu d ed in t h e s u pport o rd er, c h eck t h e b ox a fte r it e m 4 e a nd lis t t h e r e m ain in g c h ild re n w it h d ate s o f b ir th a nd s o cia l secu rit y n um be rs o n a noth er s h e et o f p aper. A tta ch t h e o th er s h ee t t o t h is f o rm .The lo ca l c h ild s u pport a gency is r e q uir e d, u nder s e ctio n 4 66(a )(1 3 ) o f t h e S ocia l S ecu rit y A ct, t o p la ce in t h e r e co rd s p erta in in g t o ch ild s u p port, t h e s o cia l s e cu rit y n um ber o f a ny in div id ual w ho is s u bje ct t o a d iv o rc e d ecre e, s u pport o rd er, o r p ate rn it y d ete rm in atio n or a ck n ow le dgm ent. T his in fo rm atio n is m andato ry a nd w ill b e k e pt o n f ile a t t h e lo ca l c h ild s u pport a gency.T op o f s e co nd p a ge, b ox o n le ft s id e : P rin t t h e n am es o f t h e p etit io ner/p la in tif f, r e sp ondent/d efe ndant, a nd o th er p are nt in t h is b ox. U se th e s a m e n am es lis te d o n t h e f r o nt p age. T op o f s e co nd p a ge, b ox o n r ig ht s id e: P rin t y o ur c o urt c a se n um ber in t h is b ox. U se t h e s a m e c a se n um ber a s o n t h e f r o nt p age, se co nd b ox, r ig ht s id e. Y ou a re r e quir e d t o c o m ple te in fo rm atio n a bout y o urs e lf . I f y o u k n ow in fo rm atio n a bout t h e o th er p ers o n, y o u m ay a ls o f ill in w hat y o u know a b out h im o r h er.5 . I f y o u a re t h e f a th er in t h is c a se , lis t y o ur f u ll n am e in t h is s p ace . S ee in str u ctio ns f o r a -g u nder it e m 6 b elo w . 6. I f y o u a re t h e m oth er in t h is c a se , lis t y o ur f u ll n am e in t h is s p ace .a. L is t y o ur d ate o f b ir th .b. W rit e y o ur s o cia l s e cu rit y n um ber.c . L is t t h e s tr e et a ddre ss, c it y , s ta te , a nd z ip c o de w here y o u liv e . d. L is t t h e s tr e et a ddre ss, c it y , s ta te , a nd z ip c o de w here y o u w ant y o ur m ail s e nt, if d if fe re nt f r o m t h e a ddre ss w here y o u liv e . e. W rit e y o ur d riv e r's lic e nse n um be r a nd t h e s ta te w here it w as is su e d. f. L is t t h e t e le phone n um ber w here y o u liv e .g. I n dic a te w heth er y o u a re e m plo ye d, s e lf - e m plo ye d, o r n ot e m plo ye d b y c h eckin g t h e a ppro pria te b ox. I f y o u a re e m plo ye d, w rit e th e n am e, s tr e e t a ddre ss, c it y , s ta te , z ip c o de, a nd t e le phone n um ber w here y o u w ork .7 . I f t h ere is a r e str a in in g o rd er, p ro te ctiv e o rd er, o r n ondis clo su re o rd er, c h eck t h is b ox.a . C heck t h e b ox b esid e e ach p ers o n w ho is p ro te cte d b y t h e r e str a in in g o rd er.b . C heck t h e b ox b esid e t h e p are n t w ho is r e str a in ed. c. W rit e t h e d ate t h e r e str a in in g o rd er e xp ir e s. S ee t h e r e str a in in g o rd er, p ro te ctiv e o rd er, o r n ondis clo su re o rd er f o r t h is d ate . If y o u a re in f e ar o f d om estic v io le nce , y o u m ay w ant t o a sk t h e c o urt f o r a r e str a in in g o rd er, p ro te ctiv e o rd er, o r n ondis clo su re o rd er. Y ou m ust t y p e o r p rin t y o ur n am e, f ill in t h e d ate , a nd s ig n t h e C hild S upport C ase R egis tr y F orm u nder p enalt y o f p erju ry . W hen y o u sig n u nd er p enalt y o f p erju ry , y o u a re s ta tin g t h at t h e in fo rm atio n y o u h ave p ro vid ed is t r u e a nd c o rre ct.F L-1 91 [R ev. J u ly 1 , 2 005]CHILD SUPPORT CASE REGISTRY FORMPage 4 o f 4e le ctr o nic f o rm  2 005 WWW.LawCA.com La w P ublis h ers