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                      page1of 2FL -3 97ATTO RNEY O R P AR TY W IT H O UT A TTO RNEY ( N am e, s ta te b ar n um ber, a nd a ddre ss):F O R C O URT U SE O NLYT E LE PH O NE N O . ( O ptio nal) :F A X N O . ( O ptio nal) :E -M AIL A D DR ESS ( O ptio nal) :A TTO RNEY F O R ( N am e):S U PER IO R C O URT O F C ALIF O RNIA , C O UNTY O FSTR EET A D DR ESSM AIL IN G A D D RESSC IT Y A N D Z IP C O DEBR AN CH N AM EP ETIT IO NER /P LA IN TIF F:R ESPO NDEN T/D EFE N DAN T:R EQ UEST F O R I N CO M E A ND B EN EFIT IN FO RM ATIO N F R O M E M PLO YERCASE N UM BERT o ( e m plo ye r n am e):1 . T his n otic e is s e rv e d o n y o u, u nd er C alif o rn ia F am ily C ode s e ctio n 3 664(b ), in r e gard t o y o ur e m plo ye e ( n am e):2 . I p re vio usly s e rv e d a r e quest f o r a n I n co m e a nd E xp ense D ecla ra tio n a fte rju dgm ent o n y o ur e m plo ye e a nd:a.T here w as n o r e sp onse w it h in 3 5 d a yso rb.T he r e sp onse w as in co m ple te a s t o w age in fo rm atio n.3 . I r e quest t h at t h e in fo rm atio n s o ught b e s e nt t o m e o n o r b efo re ( d a te ): fro m t h e d ate o f t h is r e quest., w hic h is a t le ast 1 5 d ays4 . I r e quest t h at y o u, a s t h e e m plo ye r o f t h e a bove e m plo ye e, p ro vid e t h e f o llo w in g in fo rm atio n ( in dic a te d b y c h ecke d b oxe s b elo w ). If y o u w is h , y o u m ay r e tu rn a c o py o f t h is f o rm w it h t h e in fo rm atio n f ille d o ut o r p ro vid e t h e in fo rm atio n o n a s e para te f o rm .a.b.O ccu patio n o f e m plo ye e: (1) P re se ntly e m plo ye d:Y esN o(2 ) I f e m plo ye d, c u rre nt e m plo ym ent s ta tu s: (3 ) I f n ot p re se ntly e m plo ye d: (a) D ate o f s e para tio n:Full t im ePart t im e(b ) R easo ns f o r s e para tio n:c .d.e .f.S ta rtin g d a te o f e m plo ym ent: Gr o ss s a la ry o r w ages f o r t h e p re vio us m onth ( in clu din g c o m mis sio n s, b onuse s, a nd o ve rtim e): To ta l s a la ry o r w ages f o r t h e p re vio us 1 2 m onth s ( in clu din g c o m mis sio ns, b onuse s, a nd o ve rtim e): Fe dera l in co m e t a x w it h held f o r t h e p re vio us m onth :9.S ta te in co m e t a x w it h held f o r t h e p re vio us m onth :h.i.S ocia l S ecu rit y a n d M edic a re T ax ( ''F IC A'' a nd " M ED I" ) d educte d f o r t h e p re vio us m onth : Any o th er d eductio ns f r o m t h e p aych eck f o r t h e p re vio us m onth ( fo r e ach d eductio n s ta te p urp ose a nd a m ount) : F orm A dopte d b y fo r M andit o ry U se Ju dic ia l C ouncil o f C alif o rn ia FL -3 97 [R ev. J a nuary 1 , 2 003]R EQ UEST F O R I N CO M E A ND B EN EFIT IN FO RM ATIO N F R O M E M PLO YERFam ily C ode , § 3 664ele ctr o n ic f o rm  2 002 WWW.LawCA.com La w P ublis h ers                        PETIT IO NER /P LA IN TIF F:CASE N UM BERP ETIT IO NER /P LA IN TIF F:R ESPO NDEN T/D EFE N DAN T:R ESPO NDEN T/D EFE N DAN T:J .B enefit s p ro vid ed :(1 )V is io n in su ra nceN ot a va ila bleN ot e nro lle d(2 )L if e in su ra nceN ot a va ila bleN ot e nro lle d(3 )H ealt h in su ra nceN ot a va ila bleN ot e nro lle dE nro lle d ( s p ecif y v a lu e t o e m plo ye e ): En ro lle d ( s p ecif y v a lu e t o e m plo ye e ): En ro lle d ( s p ecif y v a lu e t o e m plo ye e ):(4 )C ontr ib utio ns t o w ard re tir e m ent p la nN ot a va ila bleN ot e nro lle dE nro lle d ( s p ecif y a sse t v a lu e t o em plo ye e):(5 )U se o f c o m pany a sse ts ( v e hic le , h ousin g, h ealt h c lu b f a cilit y , e tc .)N ot a va ila bleN ot e nro lle dE nro lle d ( s p ecif y v a lu e t o e m plo ye e ):k.A tta ch a c o py o f t h e e m plo ye e's t h re e m ost r e ce nt p ay s tu bs.5 . Y ou a re e ntit le d t o h ave m e p ay t h e r e aso nable c o sts o f c o pyin g t h e in fo rm atio n in t h is r e quest.6 . U nder F am ily C ode s e ctio n 3 664(f) , y o ur c o m plia nce w it h t h is r e quest is v o lu nta ry e xce pt u pon o rd er o f t h e c o urt o r u pon agre e m ent o f t h e p artie s, e m plo ye rs , a nd e m plo ye e a ffe cte d.D ate :(T Y PE O R P R IN T N AM E)(S IG NATU RE O F R EQ UESTIN G P AR TY )N O TIC E T O E M PLO YEEI h av e s e rv ed a c o py o f t h e a tta ch ed R eq uest f o r I n co m e a nd B en efit I n fo rm atio n F ro m E m plo yer o n y our em plo ye r u nd er F am ily C ode s e ctio n 3 664(b ).U nder F am ily C ode s e ctio n 3 664(c ), y o u a re n otif ie d th at: 1. T he in fo rm atio n s o ught b y m e is lim it e d to th e in co m e a nd b enefit s p ro vid ed to y o u b y y o ur e m plo ye r. 2. T he in fo rm atio n m ay b e p ro te cte d b y r ig ht o f p riv a cy.3 . If y o u o bje ct to th e p ro ductio n o f th is in fo rm atio n b y th e e m plo ye r to m e, y o u m ust n otif y th e c o urt, in w rit in g, of th is o bje ctio n p rio r to th e d ate s p ecif ie d in p ara gra ph 3 o f th e a tta ch ed r e quest.4 . If, u p on y o ur o bje ctio n, I d o n ot a gre e, in w rit in g, to c a nce l o r n arro w th e s co pe o f m y r e quest, y o u s h ould co n su lt a n a tto rn ey r e gard in g y o ur r ig ht to p riv a cy a nd h ow to p ro te ct th is r ig ht.5 . Y ou m ay h ave o th er r ig hts p ro vid ed b y F am ily C ode s e ctio n 3 664 a nd o th erw is e .N O TIC E T O R EQ UESTIN G P A RTYU nder F am ily C ode s e ctio n 3 664(e ), s e rv ic e o f th is r e quest o n th e e m plo ye r a nd o f th e c o py o f th e r e quest o n the e m plo ye e m ust b e b y c e rtif ie d m ail, p osta ge p re paid , r e tu rn r e ce ip t r e queste d, to th e la st k n ow n a ddre ss o f the p arty to b e s e rv e d, o r b y p ers o nal s e rv ic e .FL-397 [Rev. January 1, 2003] FL-397R EQ UEST F O R I N CO M E A ND B EN EFIT IN FO RM ATIO N F R O M E M PLO YERPage tw oele ctr o n ic f o rm  2 002 WWW.LawCA.com La w P ublis h ers