Fillable Fl191 FL-191 Child Support Case Registry Form

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Fl191 FL-191 Child Support Case Registry Form

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FL-191
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):
COURT PERSONNEL:
STAMP DATE RECEIVED HERE
DO NOT FILE
CHILD SUPPORT CASE REGISTRY FORM
CASE NUMBER:
Mother First form completed
Father
THIS FORM WILL NOT BE PLACED IN THE COURT FILE. IT WILL BE
MAINTAINED IN A CONFIDENTIAL FILE WITH THE STATE OF CALIFORNIA.
Notice: Pages 1 and 2 of this form must be completed and delivered to the court along with the court order for support.
Pages 3 and 4 are instructional only and do not need to be delivered to the court. If you did not file the court order, you must
complete this form and deliver it to the court within 10 days of the date on which you received a copy of the support order.
Any later change to the information on this form must be delivered to the court on another form within 10 days of the
change. It is important that you keep the court informed in writing of any changes of your address and telephone number.
ModificationInitial child support or family support orderb.
Total monthly base current child or family support amount ordered for children listed below, plus any monthly amount ordered
payable on past-due support:
(1) Current
base child
support:
(2) Additional
monthly
support:
Person required to pay child or family support (name):
Relationship to child (if applicable):
Person or agency to receive child or family support payments (name):
TYPE OR PRINT IN INK
Page 1 of 4
Family Code, § 4014
Form Adopted for Mandatory Use
Judicial Council of California
FL-191 [Rev. July 1, 2005]
CHILD SUPPORT CASE REGISTRY FORM
www.courtinfo.ca.gov
Change to previous information
Relationship to child (specify):
TELEPHONE NO.: FAX NO. (Optional):
E-MAIL ADDRESS (Optional):
ATTORNEY FOR (Name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT:
(5)
ordered but stayed until (date):
Wage withholding was
Support order information (this information is on the court order you are filing or have received).
or
dered
(3) Total
past-due
support:
$
$
$
Date order filed:
1.
3.
2.
a.
c.
Child Support:
Family Support:
Spousal Support:
$0 (zero) order
Reserved order
(4) Payment
on past-
due support:
$
Current
base family
support:
Additional
monthly
support:
Total
past-due
support:
$
$
$
$0 (zero) order
Reserved order
Payment
on past-
due support:
$
Current
spousal
support:
Total
past-due
support:
$
$
$0 (zero) order
Reserved order
Payment
on past-
due support:
$
To keep other people from 
seeing what you entered 
on your form, please 
press the Clear This Form 
button at the end of the 
form when finished.
You are required to complete the following information about yourself. You are not required to provide information about the other
person, but you are encouraged to provide as much as you can. This form is confidential and will not be filed in the court file. It will be
maintained in a confidential file with the State of California.
Father’s name:
Date of birth:
Social security number:
Street address:
City, state, zip code:
Mailing address:
Driver’s license number:
State:
Telephone number:
Self-employedEmployed Not employed
g.
Employer’s name:
Street address:
City, state, zip code:
Telephone number:
7.
A restraining order, protective order, or nondisclosure order due to domestic violence is in effect.
Father
Mother
Children
The order protects:
Father
Mother
From:
The restraining order expires on (date):
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 COMPLETING THIS FORM)
Page 2 of 4
CHILD SUPPORT CASE REGISTRY FORM
FL-191 [Rev. July 1, 2005]
a.
b.
c.
5.
a.
b.
c.
d.
e.
f.
Mother’s name:
Date of birth:
Social security number:
Street address:
City, state, zip code:
Mailing address:
City, state, zip code:
Driver’s license number:
State:
Telephone number:
Self-employedEmployed Not employed
g.
Employer’s name:
Street address:
City, state, zip code:
Telephone number:
a.
b.
c.
6.
d.
e.
f.
City, state, zip code:
PETITIONER/PLAINTIFF:
CASE NUMBER:
RESPONDENT/DEFENDANT:
OTHER PARENT:
The child support order is for the following children:
Date of birth
Social security number
a.
b.
Add
itional children are listed on a page attached to this document.
Child’s name
4.
c.
INFORMATION SHEET FOR CHILD SUPPORT CASE REGISTRY FORM
(Do NOT deliver this Information Sheet to the court clerk.)
Please follow these instructions to complete the Child Support Case Registry Form (form FL-191) if you do not have an attorney to
represent you. Your attorney, if you have one, should complete this form.
Both parents must complete a Child Support Case Registry Form. The information on this form will be included in a national database
that, among other things, is used to locate absent parents. When you file a court order, you must deliver a completed form to the court
clerk along with your court order. If you did not file a court order, you must deliver a completed form to the court clerk WITHIN 10 DAYS
of the date you received a copy of your court order. If any of the information you provide on this form changes, you must complete a
new form and deliver it to the court clerk within 10 days of the change. The address of the court clerk is the same as the one shown for
the superior court on your order. This form is confidential and will not be filed in the court file. It will be maintained in a confidential file
with the State of California.
INSTRUCTIONS FOR COMPLETING THE CHILD SUPPORT CASE REGISTRY FORM (TYPE OR PRINT IN INK):
If the top section of the form has already been filled out, skip down to number 1 below. If the top section of the form is blank, you
must provide this information.
Page 1, first box, top of form, left side
: Print your name, address, telephone number, fax number, and e-mail address, if any, in this box.
Attorneys must include their State Bar identification numbers.
Page 1, second box, top of form, left side
: Print the name of the county and the court’s address in this box. Use the same address for
the court that is on the court order you are filing or have received.
Page 1, third box, top of form, left side: Print the names of the petitioner/plaintiff, respondent/defendant, and other parent in this box.
Use the same names listed on the court order you are filing or have received.
Page 1, fourth box, top of form, left side
: Check the box indicating whether you are the mother or the father. If you are the attorney for
the mother, check the box for mother. If you are the attorney for the father, check the box for father. Also, if this is the first time you
have filled out this form, check the box by "First form completed.” If you have filled out form FL-191 before, and you are changing any
of the information, check the box by “Change to previous information.”
Page 1, first box, right side
: Leave this box blank for the court’s use in stamping the date of receipt.
Page 1, second box, right side
: Print the court case number in this box. This number is also shown on the court papers.
Instructions for numbered paragraphs:
Enter the date the court order was filed. This date is shown in the “COURT PERSONNEL: STAMP DATE RECEIVED HERE" box
on page 1 at the top of the order on the right side. If the order has not been filed, leave this item blank for the court clerk to fill in.
If the court order you filed or received is the first child or family support order for this case, check the box by “Initial child support
or family support order." If this is a change to your order, check the box by “Modification.”
Information regarding the amount and type of support ordered and wage withholding is on the court order you are filing or have
received.
If your order provides for any type of current support, check all boxes that describe that support. For example, if your order
provides for both child and spousal support, check both of those boxes. If there is an amount, put it in the blank provided. If
the order says the amount is reserved, check the “Reserved order” box. If the order says the amount is zero, check the “$0
(zero) order" box. Do not include child care, special needs, uninsured medical expenses, or travel for visitation here These
amounts will go in (2). Do NOT complete the Child Support Case Registry form if you receive spousal support only.
If your order provides for a set monthly amount to be paid as additional support for such needs as child care, special needs,
uninsured medical expenses or travel for visitation check the box in Item 2 and enter the monthly amount. For example, if
your order provides for base child support and in addition the paying parent is required to pay $300 per month, check the box
in item 2 underneath the "Child Support" column and enter $300. Do NOT check this box if your order provides only for a
payment of a percentage, such as 50% of the childcare.
Page 3 of 4
CHILD SUPPORT CASE REGISTRY FORM
FL-191 [Rev. July 1, 2005]
1. a.
b.
c.
(1)
(2)
Write the name of the person who is supposed to pay child or family support.
Write the name of the person or agency supposed to receive child or family support payments.
List the full name, date of birth, and social security number for each child included in the support order. If there are more than five
children included in the support order, check the box below item 4e and list the remaining children with dates of birth and social
security numbers on another sheet of paper. Attach the other sheet to this form.
The local child support agency is required, under section 466(a)(13) of the Social Security Act, to place in the records pertaining to
child support the social security number of any individual who is subject to a divorce decree, support order, or paternity determination
or acknowledgment. This information is mandatory and will be kept on file at the local child support agency.
Top of page 2, box on left side: Print the names of the petitioner/plaintiff, respondent/defendant, and other parent in this box. Use the
same names listed on page 1.
Top of page 2, box on right side
: Print your court case number in this box. Use the same case number as on page 1, second box,
right side.
You are required to complete information about yourself. If you know information about the other person, you may also fill in what you
know about him or her.
If you are the father in this case, list your full name in this space. See instructions for a–g under item 6 below.
If you are the mother in this case, list your full name in this space.
List the street address, city, state, and zip code where you want your mail sent, if different from the address where you live.
Indicate whether you are employed, not employed, self-employed, or by checking the appropriate box. If you are employed, write
the name, street address, city, state, zip code, and telephone number where you work.
If there is a restraining order, protective order, or nondisclosure order, check this box.
Check the box beside the parent who is restrained.
Write the date the restraining order expires. See the restraining order, protective order, or nondisclosure order for this date.
If you are in fear of domestic violence, you may want to ask the court for a restraining order, protective order, or nondisclosure order.
You must type or print your name, fill in the date, and sign the Child Support Case Registry Form under penalty of perjury. When you
sign under penalty of perjury, you are stating that the information you have provided is true and correct.
CHILD SUPPORT CASE REGISTRY FORM
FL-191 [Rev. July 1, 2005]
Page 4 of 4
If your order provides for a specific dollar amount to be paid towards any past due support, check the box in Item 4 that states
the type of past due support and enter the amount. For example, the court ordered $350 per month to be paid on the past due
child support, you would check the box in Item 4 in the "Child Support" column and enter $350.
If your order determined the amount of past due support, check the box in Item 3 that states the type of past due support and
enter the amount. For example, if the court determined that there was $5000 in past due child support and $1000 in past due
spousal support, you would check the box in item 3 in the "Child Support" column and enter $5000 and you would also check
the box in item 3 in the "Spousal Support" column and enter $1000.
(3)
(4)
2. a.
b.
3. a.
b.
4.
Write the relationship of that person to the child.
Write the relationship of that person to the child.
6.
5.
Check the box beside each person who is protected by the restraining order.
List your date of birth.
Write your social security number.
List the street address, city, state, and zip code where you live.
Write your driver's license number and the state where it was issued.
List the telephone number where you live.
7.
a.
b.
c.
d.
e.
f.
g.
a.
b.
c.
Check the "ordered" box if wage withholding was ordered with no conditions. Check the box "ordered but stayed until" if wage
withholding was ordered but is not to be deducted until a later date. If the court delayed the effective date of the wage
withholding, enter the specific date. Check only one box in this item.
(5)
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button after you have printed the form.
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Fl191 FL-191 Child Support Case Registry Form

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Completed 2 June 2020

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