Fill and Sign the Order Declaration Form

FL-684 PETITIONER/PLAINTIFF: ––––– RESPONDENT/DEFENDANT: ––––– OTHER PARENT: ––––– CASE NUMBER: ––––– (THIS IS A REQUEST, NOT AN ORDER) I REQUEST THE FOLLOWING ORDERS FOR: Name Date of birth ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– 1. PARENTAGE. A judgment that you are the parent of these children. 2. CHILD SUPPORT. Monthly child support based on the state guideline. (An Order/Notice to Withhold income for Child Support ( FL-195.OMB No. 0970-0154 ) will be issued.) a. This is a request for a change to an existing order (1) filed on (date if known) : ––––– (2) ordering (specify) : ––––– ––––– b. Child support to commence (1) on the date this request was mailed or given to you. (2) effective (specify) : ––––– 3. HEALTH INSURANCE COVERAGE and a HEALTH INSURANCE COVERAGE ASSIGNMENT. NOTICE: The District Attorney is seeking a Health Insurance Coverage Assignment ordering your employer to enroll the above children in an appropriate health insurance plan. NOTICE: Your employer or other person providing health insurance will be ordered to enroll the children in an appropriate health insurance plan if you are found to be the parent, and a National Medical Support Notice will be issued. 4. FEES AND COSTS Fees: $ ––––– Costs: $ ––––– 5. OTHER REQUESTS (specify) : ––––– ––––– ––––– ––––– ––––– ––––– ––––– 6. FACTS IN SUPPORT of this request are: contained in an attached Declaration. ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– 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 PERSON OR REPRESENTATIVE OF GOVERNMENTAL AGENCY REQUESTING THESE ORDERS) REQUEST FOR ORDER AND SUPPORTING DECLARATIONForm Adopted by for Manditory Use Judicial Council of California FL-684 [Rev. July 1, 2003] page1 of 1el ectr onic form ã 2003 WWW.LawCA.co m L a w P u b l i s h e r s (Governmental)