Fill and Sign the Notice Regarding Payment Form

T E L E P HON E NO .: FA X N O . : S U PERIOR COURT OF CALIFORNIA, COU N TY O F FOR COUR T U S E ONLY STR E ET A DDRE S S: M A ILING A DDRE S S: CITY A ND ZIP CODE: B RANCH N A ME: OT H E R PAR E NT: NOTICE REGARDING PAYMENT OF SUPPOR T CA S E NUM B ER: NOTIC E O F ASSIGNED S UPP O RT SUBST I TUT I ON O F PAYEE 1 . T h e obli g or (the j udgment d ebto r ) in thi s p r o c e edin g i s (nam e a nd last known ad d r e ss): 2 . T h e l oca l c h il d support a gency is provid i n g s e rv i c es i n this p r o c e edin g u n der titl e IV-D of t h e Soci a l Security Act. 4 . T h e l oca l c h il d support a gency g ives n o tic e that 5 . NOTIC E OF ASSIGNME N T : An as s i gnment of su p por t rights by op e r a ti on o f law has been made to the c o unty named ab o ve un d er W e lf a r e a n d Inst i tutio ns Co d e sectio n 114 7 7(a).– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ` ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– – – ––––– ––––– ––––– ––––– ––––– ––––– – – – – – – – ––––– ––––– – – – ––––– ––––– – ––––– ––––– ––––– ––––– –G O V E RNM E NTA L A G E NC Y ( u n d e r F a mily Co d e , § § 1 7 4 0 0 , 1 7 4 0 6): FOR R E CORD E R’S US E ONLY F L - 63 2 RECORDIN G R E QU E ST E D BY A ND W HE N R E CORD E D M AI L TO: P E T ITI ON E R /PL A I N T I F F : RESPON D EN T / D E F ENDANT : 3 . T he l ocal c h ild suppor t a genc y i s no lo n ge r p r o v i ding service s a s f o llows: a . b . N o l onger enforcing curr e nt supp o rt only—arr e ars wi ll co n ti n u e to be pai d to the loc al ch i ld s u ppor t ag e ncy No l onge r providi n g a ny services a . b . th e g o v e r n me n ta l a g ency specifie d i n th e t o p l eft b ox i s substit u te d a s payee. th e j u dgment d e bt or mus t m a k e a l l cur r ent s u pport payment s in this proceed i n g t o ( s pecify): c . th e j u dgment d e bt or mus t m a k e a l l p ay m e n ts on arr e arages in this procee d ing to ( 1) th e paye e name d i n item 4 b . ( 2 ) othe r (sp e c i fy ) : d . a n abstract of support j udgment o r support j udg m en t w a s orig i nally recorded in t he co u nty o f (specify): o n ( d at e ) : a t (Record e r ’ s id e nt i ficatio n n u mb e r ): THE SU B S TITUTED P A YEE MUS T BE CONTA C TE D WHE N N O TIC E TO A LIENHOLDE R MAY OR MUS T BE GIVEN. F o rm A d o p t e d f or Ma n d at or y U s e Ju d icia l C o u n c i l of C a lifo r nia N O T I CE REGARDI N G PAYMENT OF SUPPORT P a g e 1 of 2 Fa mil y Co d e , § § 4 20 0, 4 2 0 1 , 4 2 0 4 , 4 3 5 0 , 4 3 5 1 , 4 5 0 6 . 3 , 17 4 00FL -6 3 2 [R ev . J uly 1 , 2 0 0 5 ] (Go v ernm e nta l) elec troni c form ã 2005 WWW.LawCA.co m L a w P u b l i s h e r s 7 . a . b . ––––– ––––– ––––– ––––– – – – – – – ––––– ––––– ––––– ––––– ––––– ––––– ––––– –––––PE TI TIONER/PLA I N TIFF : CA S E NUM B ER: RESP O NDENT/DEFENDAN T: O TH E R PARENT: 6 . NO T ICE O F SUPPOR T COLLEC T ION: F o r p u rp o ses of colle c tio n o nly , the governmental age n cy ide n tifie d i n th e to p l e ft box i s assi g nee of record of al l sup p ort obl i gations a s specifie d b e low and t h at age n cy wil l a p pear in this case to enforce a . a l l s u ppor t ob l igations. b. su p port arrear s o n ly. c. med i c a l o blig a ti o ns a s require d b y fe d era l law. Each pare n t m u st notify t he l ocal c h ild support a gency i n writin g withi n 1 0 d a y s o f a ny chan g e i n resi d enc e or empl o y ment. E a c h p a r e nt must com p let e a Ch i ld S u ppor t Case Reg i str y F or m (FL-19 1 ) an d file i t w i th th e c o urt wit h in 10 day s of any c h ange in reside n c e or employment. Dat e: (T Y P E OR PR INT N AM E) ( S I G N A TURE) ACKNOWL E DGMENT ( T o b e c o mp l et ed o n l y wh en this form is recorded) STATE O F CALIFORNIA COUNTY OF O n , befor e me, N o tary P u blic , p e rso n ally appe a r e d: person a ll y kn o w n to m e (or proved to m e on the basis of satisfa c tor y ev i dence) to be t he p ers o n(s) whose name(s) is/ar e su bs cri b ed to the wit h in instrument and acknowle d ged t o m e th a t he/s h e/they executed th e same i n his/ h er/their authorized capacity(ies), an d t h at by his/her/th e i r sig n at u r e ( s) on the instrum e nt the person(s), o r the entity upo n b e hal f o f which t he p ers o n(s) act e d, executed th e instru m e nt. WITNES S m y h and and offic i al s e al. ( S I G N A TURE OF NOTAR Y ) (Sea l) FL -6 3 2 [R ev . J uly 1 , 2 0 0 5 ] NOTICE REGARD I NG PAYME N T OF SUPPORT (G o ver n menta l) P a ge 2 of 2el ectr onic form ã 2005 WWW.LawCA.co m L a w P u b l i s h e r s