Fill and Sign the Uifsa Form

ATTORNEY FO R (N a me ) : SUPERIOR COUR T OF CA L I F ORNIA, COUNTY OF 3 . 4 . 5 .––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– – – ––––– – – – – ––––– ––––– ––––– – – ––––– – – ––––– ––––– – ––––– – – – ––––– – – – ––––– – – ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– – –––––G O V E RNM E NTA L A G E NC Y ( u n d e r F a mil y C od e, §§ 1 7 4 0 0 , 1 7 4 0 6) : FOR COUR T US E ONLY F L - 530 T E L E P HON E NO .: F A X NO .: E- M A I L ADD R E SS (Optio n al ) : STR E ET ADD R E S S: M A I LI NG AD D RE S S: CITY AND ZIP CODE: B RANCH N A ME: PETITIONE R: RESPONDEN T: O T HER: J U DGMENT REG A RDING PA R E N T AL OBLIGATIO NS (UIFSA) C A S E NU M B E R: A M ENDE D SUPPLE M ENTA L 1 . a . NO T I C E : T HIS IS A PR O P O SE D JUD G MEN T . T h i s J u d g ment Rega r d i ng Pare nt al O b l i g a t i o n s (U l FSA ) w i l l b e e n t e re d b y th e c o ur t an d will b ecom e leg a l l y b i n din g u nles s yo u fil l ou t an d fil e th e Re s po n se to Un i f o rm S u p p ort Petition (UlFSA ) (for m F L-520 ) wit h t h e c ou rt cler k withi n 3 0 da y s of th e d ate y ou we r e s erve d wit h th e Sum m ons (UlFSA ) (form F L -510) an d Un i f o rm S u p p ort P e ti t i o n (fo rm F L-500/OMB 097 0 - 0 085). If yo u n eed a Res p on s e form, y o u may get on e fr om th e loc a l child su p po r t a g enc y , the co urt c le r k, or the family law facilit a t o r . T he family l a w facilitator will help yo u f i l l ou t the forms. To file t he Resp o n s e, foll o w t h e pr o ced u res liste d in the inform a tion s h eet a t ta c he d t o tha t form. 2 . b . N O T I C E : TH IS IS A JUD G MEN T . I t is n o w le gal l y b i n d i n g . THIS MATTE R PROCEEDE D A S FOLLOWS: a . b . Judgment entered under Family Code sect i on 5002. By court h earing , appe a r a nces a s f o llows: ( 1 ) ( 2 ) ( 3 ) D a t e: Petitioner present Resp o ndent present Dept .: Judicial officer: Attorney presen t (na m e): Attorney presen t (na m e):( 4 ) ( 5 ) C h il d support a gency ( F am i ly C o de , § § 17 4 00, 1 7 406 ) b y (name): Othe r (sp e c i fy ) : c . T he obl i go r (the parent o r dered to pay support ) is petition er r espon d ent othe r ( s p e c i f y) : T h i s ord e r is based on presumed incom e fo r th e o b ligor und e r F a mi l y Cod e section 500 2 . Attache d is a c o mp u ter printou t sh o win g t h e p arents ’ i n c o m e an d perce n tag e o f time each paren t spe n d s wit h t he ch i ldren. T he p r i nt o ut, which s h ow s the calculatio n of c h il d suppor t p ayable, s h all become th e court’ s fin d ings. T h i s ord e r is based o n t h e a ttache d document s (specify): 6 . THE COUR T ORDERS: a . O b lig or i s th e p a r e n t of th e childre n n a me d i n item 6 b. has p r e v i ously b ee n determ i ned t o b e the paren t o f th e ch i ldren named in it e m 6b. b . O b ligor m u st pa y current c h ild suppor t a s follows: Name Date of birt h Monthly su p por t amount ( 1 ) O t her (specify): NO T ICE: Any p a rt y r eq u ir e d t o p ay chil d s up p o r t mu s t p ay inter e s t o n ove r d ue a m ou n t s a t the l e ga l r ate, w h i c h is c u rre n t ly 10 pe r cent pe r y e ar. F or m A d o p t e d for Ma n da to r y Us e J u dici a l Co u ncil o f Ca l if o r n ia F L - 5 30 [R ev. Ju ly 1, 2 0 0 5 ] JUDGMENT REGAR D ING PARENTAL OBLIGATIONS (UIFS A) P a g e 1 of 2 Fami l y C o d e § § 4 9 2 1 , 5 002elec troni c form ã 2005 WWW.LawCA.co m L a w P u b l i s h e r s P E TITI ON ER: C A S E NUM BE R: RESP ON D E N T : O T HE R : (3 ) I n teres t a c crues on t he e n tire princi p al bala n c e o w ing and no t on e ac h i nsta l lm e nt as it becomes due. For a total of: $ paya b le : $ beg i nnin g (date): A n ea r ning s a s si g nme nt o rde r fo r s u p p or t mus t i s sue. O b ligo r Obli g e e mus t ( 1) provid e a n d mai n ta i n h ealt h ins u rance coverage f o r th e c h il d ren i f it i s ava i lable through employmen t o r a group pla n , o r ot h e rw i s e ava i labl e at no o r reaso n able cost, and keep th e l o c al ch i ld suppor t a g ency informe d o f t h e a v a ila b ility of th e coverage ; ( 2 ) i f h ealt h i nsurance i s n ot avai l ab l e, pr ov ide coverage when i t becomes avai l a b le; (3) w i th i n 2 0 d ay s of th e loca l chi l d su p por t age n cy ’s requ e st , complet e an d ret u r n a he a lt h i n s u r a nce form ; (4) provi d e t o the loca l chi ld su p port ag e ncy al l i n formation and forms necessar y t o o bt a in health-care s e rvice s for th e chi l dren ; (5 ) p r e s e nt a ny claim to secure paym e nt or r e im b urs e m e n t t o the ot h e r p a r e n t or c a r e taker who incur s cost s fo r h ealth-car e services for t h e chil d r e n; an d (6) ass i gn an y ri g hts t o rei m bursement t o th e othe r parent or caretake r who incur s cost s for health-care servic e s for th e childre n. If th e “Ob l igor” b ox i s checked , a he a lt h i n s u r a nce covera g e a s si g nm e n t mus t issue. T he N o tice o f R i ghts an d Resp o nsibi l it i e s a nd Informatio n She e t on Chan g ing a Child Supp o rt Orde r (f o r m FL-19 2 ) is attache d . Obl i go r mus t p a y costs of: $ The court furth e r order s (sp e c i fy ) :––––– ––––– ––––– ––––– – ––––– ––––– – – ––––– ––––– ––––– – ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– – ––––– ––––– – ––––– ––––– ––––– ––––– – ––––– ––––– ––––– – – – ––––– – ––––– ––––– ––––– ––––– ––––– – –––––6. b . ( 2 ) F o r a t ot a l o f : $ beg i nnin g (date): paya b le o n the : da y of eac h month (3 ) T h e l ow-income a djustme nt app l ies. T he low-income adjustmen t do es not apply becaus e (specify reaso n s): c . (4 ) Any su p por t ordere d wi l l co n ti n u e unti l further o r d e r of c o urt , u nles s terminated b y o perat i on of law. O b ligor m u st pa y ch i ld suppor t fo r the pas t p e r i ods and in th e amou n ts s e t f o rth belo w : Nam e Date of birt h Perio d of s u ppor t Amo u nt (1 ) Othe r (sp e c i fy ) : ( 2 ) on the: da y of e a c h month d . e . No provision o f this jud g me n t operates t o limi t a n y rig h t to coll e ct th e pri n c i pal ( t otal amount of unp a id s u pport) o r t o c h a r ge a nd coll e ct interest and pe n altie s a s al l owed b y l aw . All payments ordere d are subj e c t to modification. All payments must be m a de t o (name and address of ag e ncy): f . g . h . T h e parents must notify th e loca l chil d s up p ort age n cy in writ i ng wit h in 10 day s o f an y ch a nge in residence or em p loym e nt. i . j . k .D a t e: J UDICIA L OFFICER 7 . N um b er of p age s attache d : S IG NATUR E F O L L O W S L A ST ATT A CHM E NT Approved as c o nf o r min g to c o urt order: Date: ( S I G N A TURE OF A T TORN E Y FOR OB L IGO R ) F L - 5 3 0 [R ev . Ju l y 1 , 2 00 5] J U DGMENT REG A RDING PA R E N T AL OBLIGATIO N S (UIFS A) P a ge 2 of 2elec troni c form ã 2005 WWW.LawCA.co m L a w P u b l i s h e r s