PETITIONER / PLAINTIFF:
RESPONDENT / DEFENDANT:
(THIS IS A REQUEST, NOT AN ORDER)
I REQUEST THE FOLLOWING ORDERS FOR:
Date of birth Name of child Date of birth
PARENTAGE. If not previously established, a judgment that you are the parent of the children named above.
CHILD SUPPORT. Monthly child support based on the state guideline. (An Income Withholding for Support (FL-195/OMB No.
0970-0154) will be issued.)
This is a request for a change to an existing order
(2) ordering (specify):
b. Child support to commence
c. Other (specify):
HEALTH INSURANCE COVERAGE
If not previously ordered, an order that you provide health insurance for each child named above and an order that you
complete the attached health insurance form and immediately return it to the local child support agency.
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.
FEES AND COSTS
Fees: $ Costs: $
5. PROPERTY RESTRAINT
Petitioner/plaintiff Other parentRespondent/defendant
be restrained from transferring, encumbering, hypothecating, concealing, or in any way disposing of the following property
Page 1 of 2
Form Adopted for Mandatory Use
Judicial Council of California
FL-684 [Rev. January 1, 2010]
Family Code §§ 215, 3751, 3761,
3900-3901, 4001-4062, 4007, 4009, 4014,
REQUEST FOR ORDER AND SUPPORTING DECLARATION
4050-4076, 4200-4204, 7551,17304, 17400,
Name of child
(1) filed on (date if known):
(1) on the date this request was mailed or given to you.
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.