Fill and Sign the Stipulation and Order129922 Fl 625 Family Law Governmental 129922 Fl 625 Form

FL-625 GOVERNMENTAL AGENCY (pursuant to Welf. & Inst. Code, §§ 11475.1, 11478.2): TELEPHONE AND FAX NOS.: E- MAIL AD DR ESS (Op tio nal ): ATTO RN EY F O R (N am e): FOR COURT USE ONLY S UPER IO R C O URT O F C ALIF O RNIA , C O UNTY O F STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT: STIPULATION AND ORDER C ASE N UM BER : 1. THIS MATTER PROCEEDED AS FOLLOWS:a. By written stipulation without court appearance. b. By court hearing, appearances as follows: (1)Date: Dept.: Judicial officer: (2) Petitioner/Plaintiff present Attorney present (name): (3) Respondent/Defendant present Attorney present (name): (4) Other parent present Attorney present (name): (5) Loca l ch ild su pp ort a g e ncy ( F am ily C ode, § § 1 7400, 1 7406 ) by (n am e): (6) Other (specify): c. The Obligor (the parent ordered to pay support) is Petitioner/Plaintiff Respondent/Defendant Other parent 2. This order is based on the attached documents (specify): 3. THE PARTIES AGREE THATa. All o rd ers p re vio usly m ade in t h is a ctio n s h all r e m ain in f u ll f o rc e a nd e ffe ct e xce pt a s s p ecif ic a lly m odif ie d b elo w .b. The amount of support payable by obligor as calculated under the guideline is: $ per month. We agree to guideline support.The guideline amount should be rebutted because of the following: (1) We h ave b een f u lly in fo rm ed o f t h e g uid elin e a m ount o f s u pport; w e a gre e v o lu nta rily t o c h ild s u pport of: $ p er m onth ; th e ag re em en t is in the best in te re st o f th e c h ild re n; the ne eds o f the ch ild re n. w il l b e m et a d eq uate ly b y th e a gre ed a m ount; th e c h ild re n are n o t re ce iv in g p ublic a ssis ta nce ; n o app lic a tio n for p ublic ass is ta nce is pe nd ing ; a n d app lic a tio n o f th e g uide lin e w ou ld b e u nju st an d in ap p rop ria te in t h is ca se . W e u nder sta nd that if th e ord er is be lo w g uid elin e, n o c h ange o f cir c u m stan ce s nee d b e s h ow n to r a is e thi s o rd er to the guid e lin e am ount. If th e ord er is a bove the guid e lin e, a c h ange of c ir c um sta n ce s w ill b e r e quir e d to m odif y this o rder.(2) Other rebutting factors (specify) : NOTICE: Any party required to pay child support must pay interest on overdue amounts at the "legal" rate, which is currently 10 percent. This can be a large added amount. Pag e o ne o f t h re e STIPULATION AND ORDER (Governmental) Family Code, §§ 17400, 17404, 17406 Form Adopted by for Manditory Use Judicial Council of California FL- [Rev. July 1, 2005]ele ctr o nic f o rm  2004,5 WWW.LawCA.com La w P ublis h ers PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT: CASE NUMBER 3. c. Atta ch ed is a c o m pute r p rin to ut s h ow in g t h e p are nt's in co m e a nd p erc e nta ge o f t im e e ach p are nt s p ends w it h t h e c h ild (r e n). The printout, which shows the calculation of child support payable, shall become the court's findings. d.Obligor shall pay current child support as follows:NameDate of birthMonthly support amount (1) Other (specify): (2) For a total of: $ payable on the: day of each month beginning (date): (3) The support order was reduced, pursuant to the low-income adjustment, because the Obligor's net monthly income is less than $1,000. (4) Any support ordered shall continue until further order of court, unless terminated by operation of law.e. Obligor owes child support arrears as follows, as of (date): (1) Child support: $ Spousal support: $ Family support: $ (2) Interest is not included and is not waived.(3) Payable:$ on the day of each monthbeginning (date): (4) Interest shall accrue on the entire principal balance owing and not on each installment as it becomes due.f. No provision of this judgment shall operate to limit any right to collect the principal (total amount of unpaid support) or to charge and collect interest and penalties as allowed by law. All payments ordered are subject to modification.g. All payments shall be made to (name and address of agency): h. An Order/Notice to Withhold Income for Child Support (form FL-195) will issue..i. Obligor Obligee shall (1) provide and maintain health insurance coverage for the children if it is available through employment, a group plan, or otherwise available at no or reasonable cost, and shall keep the district attorney's office informed of the availability of the coverage; (2) if health insurance is not available, provide coverage when it becomes available; (3) within 20 days of the district attorney's request, complete and return a health insurance form; (4) provide to the district attorney all information and forms necessary to obtain health care services for the children; (5) present any claim to secure payment or reimbursement to the other parent or caretaker who incurs costs for health care services to the children; (6) assign any rights to reimbursement to the other parent or caretaker who incurs costs for health care services for the children. If the "obligor" box is checked, a Health Insurance Coverage Assignment shall issue. j. The par en ts m us t n otif y the loca l c hi ld s u pport ag ency in w rit in g wit h in 10 day s of any ch ange in r e side nce o r e m ploy ment.K. The Notice of Rights and Responsibilities—Health-Care Costs and Reimbursement Procedures and Information Sheet on Changing a Child Support Order (form FL-192) is attached. STIPULATION AND ORDER (Governmental) Page two of three FL-625 [Rev. July 1, 2005]e le ctr o nic f o rm  2004,5 WWW.LawCA.com La w P ublis h ers PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT: CASE NUMBER 3. k. The fo llo w in g per so n (th e “ ot her p are nt ”) is a dded as a p arty to th is a ctio n u nder F am ily C ode s e ctio n 1 7404 (n am e): l. Other (specify): D ate : (TYPE OR PRINT NAME) (SIGNATURE OF ATTORNEY for local child support agency) Date : (TYPE OR PRINT NAME)(SIGNATURE OF FATHER) Date : (TYPE OR PRINT NAME) (SIGNATURE OF ATTORNEY FOR FATHER) Date : (TYPE OR PRINT NAME)(SIGNATURE OF MOTHER) Date : (TYPE OR PRINT NAME) (SIGNATURE OF ATTORNEY FOR MOTHER) ORDER 4. The court so orders.Date: (JUDICIAL OFFICER) Signature follows last attachment 5.Number of pages attached:  STIPULATION AND ORDER (Governmental) Page three of three FL-625 [Rev. July 1, 2005]e le ctr o nic f o rm  2004,5 WWW.LawCA.com La w P ublis h ers