The hardship will last until (date):
A hardship is being experienced by the father: $
per month because of (specify):
Form Adopted for Mandatory Use
Judicial Council of California
FL-350 [Rev. January 1, 2020]
STIPULATION TO ESTABLISH OR MODIFY
CHILD SUPPORT AND ORDER
Family Code, § 4065
www.courts.ca.gov
Page 1 of 2
PARTY WITHOUT ATTORNEY OR ATTORNEY
STATE BAR NUMBER:
NAME:
FIRM NAME:
STREET ADDRESS:
CITY: STATE: ZIP CODE:
TELEPHONE NO.: FAX NO.:
E-MAIL ADDRESS:
ATTORNEY FOR (name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
OTHER PARENT/PARTY:
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
FOR COURT USE ONLY
FL-350
STIPULATION TO ESTABLISH OR MODIFY
CHILD SUPPORT AND ORDER
CASE NUMBER:
1.
-OR-
b. A printout of a computer calculation of the parents’ financial circumstances is attached.
2.
3.
b.
, referred to as “the parent ordered to
per month.
%
per month because of (specify):
5.
We agree to guideline support.
6.
per month; the agreement is in the best interest of the
children; the needs of the children will be adequately met by the agreed amount; and application of the guideline would
be unjust or inappropriate in this case.
a.
b.
BASIC CHILD SUPPORT
Monthly amount
Payable to (name):
payable on the first of the month
In addition, the parent ordered to pay support must pay the following:
b.
per month for special educational or other needs of the children
c.
on the first of the monthpayable
Child’s name
per month for health-care costs not covered by insurance
The guideline amount should be rebutted because of the following:
(1)
(2)
(3)
(4)
on (date):
on (date):
on (date):
to (name):
to (name):
per month for child care costs to (name):
$
$
$
A hardship is being experienced by the mother: $
The hardship will last until (date):
Mother’s net monthly disposable income: $
Father’s net monthly disposable income: $
4.
The amount of child support payable by (name):
pay support," as calculated under the guideline is: $
We agree to child support in the amount of: $
Other rebutting factors (specify):
Total: $
other (specify):
Father:
Total monthly child support payable by the parent ordered to pay support will be: $
other (specify):
other (specify):
The parent ordered to pay support must pay child support as follows beginning (date):
7.
a.
a.
a.
Percentage of time each parent has primary responsibility for the children: Mother:
Health insurance will be maintained by (specify name):
8. a.
The parent ordered to provide health insurance must seek continuation of coverage for the child after the child attains the age
when the child is no longer considered eligible for coverage as a dependent under the insurance contract, if the child is
incapable of self-sustaining employment because of a physically or mentally disabling injury, illness, or condition and is chiefly
dependent upon the parent providing health insurance for support and maintenance.
%
FL-280 [Rev. January 1, 2020]
STIPULATION TO ESTABLISH OR MODIFY
CHILD SUPPORT AND ORDER
Page 2 of 2
FL-350
RESPONDENT/DEFENDANT:
OTHER PARENT/PARTY:
PETITIONER/PLAINTIFF:
CASE NUMBER:
We agree that service of the earnings assignment be stayed because we have made the following alternative
b.
11.
12.
13.
We agree that we are fully informed of our rights under the California child support guidelines.
We make this agreement freely without coercion or duress.
The right to support
has not been assigned to any county, and no application for public assistance is pending. a.
b.
If you checked b, an attorney for the local child support agency must sign below, joining in this agreement.
(TYPE OR PRINT NAME)
(SIGNATURE OF ATTORNEY FOR LOCAL CHILD SUPPORT AGENCY)
Notice: If the amount agreed to is less than the guideline amount, no change of circumstances need be shown to obtain a change in
the support order to a higher amount. If the order is above the guideline, a change of circumstances will be required to modify this
order. This form must be signed by the court to be effective.
(SIGNATURE OF PETITIONER)
(TYPE OR PRINT NAME) (SIGNATURE OF RESPONDENT)
(TYPE OR PRINT NAME)
(SIGNATURE OF OTHER PARENT)
(TYPE OR PRINT NAME) (SIGNATURE OF ATTORNEY FOR PETITIONER)
THE COURT ORDERS
The guideline child support amount in item 4 is rebutted by the factors stated in item 6.17.
Items 7 through 13 are ordered. All child support payments must continue until further order of the court, or until the child
marries, dies, is emancipated, or reaches age 18. The duty of support continues as to an unmarried child who has attained the
age of 18 years, is a full-time high school student, and resides with a parent, until the time the child completes the 12th grade or
attains the age of 19 years, whichever first occurs. Except as modified by this stipulation, all provisions of any previous orders
made in this action will remain in effect.
JUDICIAL OFFICER
An earnings assignment order is issued.
We agree that we will promptly inform each other of any change of residence or employment, including the employer’s
name, address, and telephone number.
10.
14.
15.
16.
a.
In the event that there is a contract between a party receiving support and a private child support collector, the party ordered to
pay support must pay the fee charged by the private child support collector. This fee must not exceed 33 1/3 percent of the total
amount in arrears nor may it exceed 50 percent of any fee charged by the private child support collector. The money judgment
created by this provision is in favor of the private child support collector and the party receiving support, jointly.
9.
b.
8.
arrangements to ensure payment (specify):
Other (specify):
Date:
Date:
Date:
Date:
Date:
Date:
Father:b.
a.
has been assigned or an application for public assistance is pending in (county name):
(TYPE OR PRINT NAME)
(SIGNATURE OF ATTORNEY FOR RESPONDENT)
(TYPE OR PRINT NAME)
(SIGNATURE OF ATTORNEY FOR OTHER PARENT)
Date:
Date:
(TYPE OR PRINT NAME)
NOTICE: Any party required to pay child support must pay interest on overdue amounts at the “legal” rate, which is
currently 10 percent per year. This can be a large added amount.
% %
Mother:
Any health expenses not paid by insurance will be shared:
Father:
% %
Mother:
Travel expenses for visitation will be shared:
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