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SHC-P-04 (Rev. 01/01/2021)
SelfHelpFamilyLaw@occourts.org 657.622.6630
SUPERIOR COURT OF CALIFORNIA
COUNTY OF ORANGE
Self-Help Services
www.occourts.org/self-help
CHILD VISITATION (PARENTING TIME) should be ordered as set forth in the proposed Judgment (form FL-250).
Petition to Determine Parental Relationship Response
Petition for Custody and Support of Minor Children
1.
I request that proof will be by this declaration and that I will not appear before the court unless I am ordered by the court to appear.
3.
5.
DEFAULT OR UNCONTESTED (Check a or b)
13.
I have read and understand the Advisement and Waiver of Rights Re: Determination of Parental Relationship (form FL-235), which
is signed and attached to this declaration.
14.
This declaration may be reviewed by a commissioner sitting as a temporary judge who may determine whether to grant this request
or require my appearance.
6.
7.
9.
12.
NAMES OF THE CHILDREN should be changed as set forth in the proposed Judgment (form FL-250).
11.
REASONABLE EXPENSES OF PREGNANCY AND BIRTH should be ordered as set forth in the proposed Judgment (form
FL-250).
10.
CHILD CUSTODY should be ordered as set forth in the proposed Judgment (form FL-250).
ATTORNEY FEES should be ordered as set forth in the proposed Judgment (form FL-250).
8.
CHILD SUPPORT should be ordered as set forth in the proposed Judgment (form FL-250).
PetitionerRespondent and/or4.
All the information in the
2.
I declare that if I appeared in court and were sworn, I would testify to the truth of the facts in this declaration.
Petitioner
b.
a.
Form Adopted for Mandatory Use
Judicial Council of California
FL-230 [Rev. January 1, 2020]
Family Code, §§ 7600, 3120,
3900 et seq.
www.courts.ca.gov
DECLARATION FOR DEFAULT OR UNCONTESTED JUDGMENT
(Uniform Parentage, Custody and Support)
Page 1 of 1
The parties have stipulated (agreed in writing) that the matter may proceed as an uncontested matter without notice, and
the stipulation is attached.
FL-230
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:
RESPONDENT:
PETITIONER:
DECLARATION FOR DEFAULT OR UNCONTESTED JUDGMENT
FOR COURT USE ONLY
CASE NUMBER:
b.
has not
has
(SIGNATURE OF DECLARANT)
Date:
(TYPE OR PRINT NAME)
Response
is true and correct.
is/are the parent(s) of the minor children.
A voluntary declaration of parentage or paternity form
been signed regarding these children (attach a
Respondent
is presently receiving public assistance (TANF); thus all support should be made
payable to the local child support agency at (specify address):
NOTE: If a support order is requested, submit a completed Income and Expense Declaration (form FL-150), or
Financial Statement (Simplified) (form FL-155), unless a current form is on file. Include your best estimate of the other
party's gross monthly income.
15.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
copy if available).
a.
The default of the respondent was entered or is being requested, and I am not seeking any relief not requested in the
petition. OR
Other (specify):
ORANGE
341 THE CITY DRIVE SOUTH
341 THE CITY DRIVE SOUTH
ORANGE, CA92868
LAMOREAUX JUSTICE CENTER
Form Adopted for Mandatory Use
Judicial Council of California
FL-240 [Rev. January 1, 2021]
STIPULATION FOR ENTRY OF JUDGMENT RE:
DETERMINATION OF PARENTAL RELATIONSHIP
(Uniform Parentage—Custody and Support)
Family Code, § 7600 et seq.
FL-240
FOR COURT USE ONLY
CASE NUMBER:
PARTY WITHOUT ATTORNEY or ATTORNEY STATE BAR NO.:
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
BRANCH NAME:
CITY AND ZIP CODE:
STREET ADDRESS:
MAILING ADDRESS:
PETITIONER:
RESPONDENT:
OTHER PARENT/PARTY:
STIPULATION FOR ENTRY OF JUDGMENT RE:
DETERMINATION OF PARENTAL RELATIONSHIP
THE PARTIES STIPULATE THAT
1.
The parties read and understand the Advisement and Waiver of Rights Re: Determination of Parental Relationship
(form FL-235), which is submitted with this Stipulation for Entry of Judgment. The parties give up those rights and freely agree
that a judgment may be entered in accordance with this stipulation.
2.
Name:
Name:
are the parents of the following children:
Name
Date of Birth
THE PARTIES STIPULATE THAT THE COURT ORDER:
3.
Child custody and visitation (parenting time) as proposed in
Judgment
(Uniform Parentage—Custody and Support) (form ).
4.
Child support as proposed in Judgment (Uniform Parentage—Custody and Support) (form ).
5.
Attorney fees as proposed in Judgment (Uniform Parentage—Custody and Support) (form ).
6.
Changes to the names of children as proposed in Judgment (Uniform Parentage—Custody and Support) (form ).
7.
Reasonable costs of pregnancy and birth as proposed in Judgment (
Uniform Parentage—Custody and Support)
(form ).
8.
Other orders as proposed in Judgment (Uniform Parentage—Custody and Support) (form ).
9.
The parties further agree that the court make the following orders:
See attachment 9.
Date:
(TYPE OR PRINT NAME)
(SIGNATURE OF PETITIONER)
Date:
(TYPE OR PRINT NAME)
(SIGNATURE OF RESPONDENT)
Date:
(TYPE OR PRINT NAME)
(SIGNATURE OF ATTORNEY FOR PETITIONER)
Date:
(TYPE OR PRINT NAME)
(SIGNATURE OF ATTORNEY FOR RESPONDENT)
Date:
(TYPE OR PRINT NAME)
(SIGNATURE OF OTHER PARTY OR ATTORNEY)
Page 1 of 1
www.courts.ca.
g
o
v
FL-250
FL-250
FL-250
FL-250
FL-250
FL-250
Orange
341 The City Drive South
P.O. Box 14710
Orange, CA 92868
Lamoreaux Justice Center
Form Approved for Optional Use
Judicial Council of California
FL-130 [Rev. January 1, 2021]
APPEARANCE, STIPULATIONS, AND WAIVERS
(Family Law—Uniform Parentage—Custody and Support)
Government Code, § 70673
FL-130
FOR COURT USE ONLY
CASE NUMBER:
PARTY WITHOUT ATTORNEY or ATTORNEY STATE BAR NO.:
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:
PETITIONER:
RESPONDENT:
APPEARANCE, STIPULATIONS, AND WAIVERS
1.
Appearance by respondent (you must choose one):
a.
By filing this form, I make a general appearance.
I have previously made a general appearance.
c.
I am a member of the military services of the United States of America. I have completed and attached to this form
Declaration and Conditional Waiver of Rights Under the Servicemembers Civil Relief Act of 2003 (form FL-130(A)).
b.
2.
Agreements, stipulations, and waivers (choose all that apply):
a.
The parties agree that this cause may be decided as an uncontested matter.
b.
The parties waive their rights to notice of trial, a statement of decision, a motion for new trial, and the right to appeal.
c.
This matter may be decided by a commissioner sitting as a temporary judge.
d.
The parties have a written agreement that will be submitted to the court, or a stipulation for judgment will be submitted to
the court and attached to Judgment (Family Law) (form FL-180).
e.
None of these agreements or waivers will apply unless the court approves the stipulation for judgment or incorporates
the written settlement agreement into the judgment.
f.
This is a parentage case, and both parties have signed an Advisement and Waiver of Rights Re: Determination of
Parental Relationship (form FL-235) or its equivalent.
3.
Other (specify):
Date:
(TYPE OR PRINT NAME)
(SIGNATURE OF PETITIONER)
Date:
(TYPE OR PRINT NAME)
(SIGNATURE OF RESPONDENT)
Date:
(TYPE OR PRINT NAME)
(SIGNATURE OF ATTORNEY FOR PETITIONER)
Date:
(TYPE OR PRINT NAME)
(SIGNATURE OF ATTORNEY FOR RESPONDENT)
Page 1 of 1
www.courts.ca.
g
o
v
O
range
341 The City Drive South
Orange, CA 92868
Lamoreaux Justice Center
P.O. Box 14710
L-1301 (Rev. 08/27/2015)
Approved for Optional Use
Expedited Processing Attachment and Stipulation Paternity Judgment Page 1 of 4
EXPEDITED PROCESSING ATTACHMENT TO PATERNITY
JUDGMENT
CASE NUMBER:
WARNING: This Attachment only includes the minimum statutory requirements at the time of entry of judgment.
It does not replace the stipulated judgment or other required documents.
I. CHILD CUSTODY/VISITATION PURSUANT TO FC §3048
(1) This court has jurisdiction to make child custody orders in this case under the Uniform Child Custody
Jurisdiction and Enforcement Act (part 3 of the California Family Code commencing with section
3400).
(2) The responding party was given notice and an opportunity to be heard as provided by the laws of the
State of California.
(3) The country of habitual residence of the child(ren) is:
the United States
other (specify country): _____________________________________________
(4) If you violate this order you may be subject to civil or criminal penalties, or both.
(5) The judgment contains a clear description of the custody and visitation rights of each party.
II. CHILD SUPPORT
a. FINDINGS PURSANT TO FC §3901 and §4065
(1) The Parties are fully informed of their rights concerning child support.
(2) The order is being agreed to without coercion or duress.
(3) The agreement is in the best interests of the child(ren) involved.
(4) The needs of the child(ren) will be adequately met by the stipulated amount.
(5) Unless otherwise indicated, the right to support has not been assigned to the county pursuant to
Section 11477 of the Welfare and Institutions Code and no public assistance application is pending.
b. MONEY JUDGMENT IN COURT ORDER PURSUANT TO FC §5616
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 of past due support 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.
L-1301 (Rev. 08/27/2015)
Approved for Optional Use
Expedited Processing Attachment and Stipulation Paternity Judgment Page 2 of 4
c. BASE CHILD SUPPORT
Please check all appropriate boxes. At least one (1) box must be checked:
CHILD SUPPORT IS RESERVED (If checked, skip directly to section III)
CHILD SUPPORT SERVICES INVOLVED
The parties currently have an open case with the Child Support Services (CSS) and a
CSS representative has signed the proposed judgment.
The parties currently have an open case with CSS, no child support orders are
contained in this judgment, and the court reserves jurisdiction over the issue of child
support, health insurance coverage, and additional child support.
If checked, skip directly to section III.
AGREED UPON SUPPORT
Petitioner Respondent shall pay to Petitioner Respondent base child support of
$_____________ per week month, payable $ ______________ on the
________________ and $ ________________ on the ________________ of each
week month, commencing ________________ and continuing until the
child(ren) for whom support is payable: marries, dies, is emancipated, until further order
of the court or, as to an unmarried child who has attained the age of 18 years old, is a full-
time high school student, and who is not self-supporting, until the time the child
completes the 12th grade or attains the age of 19 years old, whichever first occurs.
d. MANDATORY ADDITIONAL CHILD SUPPORT PURSUANT TO FC §4062
Petitioner Respondent shall pay child care costs related to employment or reasonably necessary
education/job training:
in the amount of $ ________________ per week month or ____ % of total.
No child care costs orders are contained in this judgment and the court
reserves jurisdiction over the issue of child care costs.
Petitioner
Respondent shall pay the reasonable uninsured health care costs for the child(ren):
in the amount of $ ________________ per week month or ____ % of total.
e. DISCRETIONARY ADDITIONAL CHILD SUPPORT PURSUANT TO FC §4062
Petitioner Respondent shall pay costs related to ___________________________________
_____________________________________________________________________________:
in the amount of $ ________________ per week month or _____ % of total.
f. TOTAL CHILD SUPPORT
Petitioner Respondent shall pay to
Petitioner
Respondent base child support of $____________ per
week month, plus additional child support as specified in sections (d) and/or (e) in the section above,
for a total of $___________ per week month, payable $ ________________ per week month,
$ ________________ on the ________________ and $ ________________ on the ________________ of
each week month, commencing on ______________ and continuing until the child(ren) for
whom support is payable: marries, dies, is emancipated, until further order of the court or, as to an
unmarried child who has attained the age of 18 years old, is a full-time high school student, and who is
not self-supporting, until the time the child completes the 12th grade or attains the age of 19 years old,
whichever first occurs.
L-1301 (Rev. 08/27/2015)
Approved for Optional Use
Expedited Processing Attachment and Stipulation Paternity Judgment Page 3 of 4
g. REQUIRED ATTACHMENT PURSUANT TO FC §4063 and §7600
The parties have attached the following form: “Notice of Rights and Responsibilities: Health Care Costs
and Reimbursement Procedures and Information sheet on Changing a Child Support Order” (FL-192).
h. HEALTH INSURANCE COVERAGE PURSUANT TO FC §3751
If child support is not reserved, at least one (1) of the following boxes must be checked.
Health insurance coverage for the minor child(ren) must be maintained by Petitioner Respondent if that
insurance is available at no cost or at reasonable cost to the parent(s) through their respective places of
employment or self-employment. Both parties are ordered to cooperate in the presentation, collection, and
reimbursement of any health care claims. 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.
Health Insurance is not available to the
Petitioner
Respondent at a reasonable cost at this time.
Should health insurance coverage become available to a parent for no or for reasonable cost, that parent
must apply for that coverage.
i. INCOME WITHHOLDING FOR CHILD SUPPORT PURSUANT TO FC §5230
An Income Withholding for Child Support (form FL-195) is issued. Note: The payor of child support is
responsible for the payment of support directly to the recipient until support payments are deducted from
the payor's wages, and for any support not paid by the assignment.
j.
EMPLOYER INFORMATION PURSUANT TO FC §4014
The parties must notify the other parent of the name and address of his or her current employer.
III. MISCELLANEOUS PROVISIONS
The Settlement Agreement/Stipulated Judgment that is also attached to the Judgment (form FL-250) contains
further orders.
All provisions are deemed incorporated into the Judgment. As to the provisions that contain a checkbox ( ),
only those provisions that are checked become part of the Judgment.
If there is any express conflict between the Settlement Agreement/Stipulated Judgment and this Expedited
Processing Attachment, the Expedited Processing Attachment prevails. However, this Expedited Processing
Attachment is not all inclusive. The fact that this Expedited Processing Attachment is less detailed is not a
conflict. The Expedited Processing Attachment only includes the minimum statutory requirements at the time
of entry of judgment. It does not replace the stipulated judgment or other required documents.
✔
L-1301 (Rev. 08/27/2015)
Approved for Optional Use
Expedited Processing Attachment and Stipulation Paternity Judgment Page 4 of 4
IV. STIPULATION FOR JUDGMENT
The parties agree that the Judgment (form FL-250) and all attachments, including this Expedited Processing
Attachment, contain the exact terms of the Judgment to be entered in this case.
Approved as confirming to the agreement of the parties:
Each attachment to this judgment is incorporated into this judgment, and the parties are ordered to comply
with each attachment’s provisions. Jurisdiction is reserved to make other orders necessary to carry out this
judgment.
_________ _____________________________________
Date Judge / Commissioner of the Superior Court
I declare under penalty of perjury under the laws of the State of California that the foregoing is true
and correct and agreed to by:
*: If Judgment is being submitted by way of a Stipulated Default (no Response [form FL-220] or Appearance,
Stipulations and Waivers [form FL-130] has been filed), then the Respondent's signature must be notarized and
must comply with Civil Code §1189.
______________________________________
Petitioner: Date
_____________________________________
Respondent: Date
______________________________________
Date
Attorney for Petitioner
______________________________________
Date
Attorney for Petitioner
Other parties or attorneys present (specify):
1.
Judicial officer (name):
Default or uncontested
This judgment
This matter proceeded as follows:
The restraining orders are contained in item(s):
2.
THE COURT FINDS
4. THE COURT ORDERS
3.
a.
Form Adopted for Mandatory Use
Judicial Council of California
FL-250 [Rev. January 1, 2020]
Family Code, §§ 3120, 3900,
7600 et seq.
www.courts.ca.gov
JUDGMENT
(Uniform Parentage—Custody and Support)
Page 1 of 2
contains personal conduct restraining orders modifies existing restraining orders.
FL-250
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:
PETITIONER:
RESPONDENT:
JUDGMENT
FOR COURT USE ONLY
CASE NUMBER:
b.
c.
a. Child custody and visitation are as specified in one or more of the attached forms:
Petitioner present
of the attachment.
They expire on (date):
A CLETS form must be attached.
By declaration
Contested
Date:
Dept.: Room:
Temporary judge
(name):
Attorney present
Attorney present
Respondent present
(name):
d.
e.
f.
Respondent
h.
g.
Petitioner (1) The petitioner appeared without counsel and was advised of relevant rights.
(3) The petitioner is married to the respondent, and no other action is pending.
(3)
The respondent is married to the petitioner, and no other action is pending.
(5) There is a prior judgment of parentage in a family support, juvenile or adoption court case.
(4) The respondent signed a voluntary declaration of parentage or paternity.
(2)
The respondent signed Advisement and Waiver of Rights Re: Determination of Parental Relationship
(form FL-235).
(1) The respondent appeared without counsel and was advised of relevant rights.
(5) There is a prior judgment of parentage in a family support, juvenile, or adoption court case.
(4) The petitioner signed a voluntary declaration of parentage or paternity.
(2)
The petitioner signed Advisement and Waiver of Rights Re: Determination of Parental Relationship
(form FL-235).
Name:
are the parents of the following children:
Name:
Name:
Child's name
Date of birth
(1)
Child Custody and Visitation Order Attachment (form FL-341)
(3) Other
(2)
Stipulation and Order for Custody and/or Visitation of Children (form FL-355)
(specify):
ORANGE
341 THE CITY DRIVE SOUTH
341 THE CITY DRIVE SOUTH
ORANGE, CA 92868
LAMOREAUX JUSTICE CENTER
RESPONDENT:
PETITIONER:
CASE NUMBER:
FL-250
Date:
(TYPE OR PRINT NAME)
5. THE COURT FURTHER ORDERS
a.
changing the last name of the children.(2)
adding(1)
f.
Reasonable expenses of pregnancy and birth are as stated in the attachment.g.
Attorney fees and costs are as stated in the attached Attorney's Fees and Costs Order Attachment (form FL-346).
The birth certificates must be amended to conform to this court order bye.
The last names of the children are changed to d.
Both parties must complete and file with the court a Child Support Case Registry Form (form FL-191) within 10 days of the
date of this judgment. Thereafter, the parents must notify the court of any change in the information submitted, within 10 days
of the change.
c.
b.
Child support is as stated in one or more of the attached:
(1)
Child Support Information and Order Attachment (form FL-342)
(3)
Other
(2)
Stipulation to Establish or Modify Child Support and Order (form FL-350)
(specify):
The form 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.
(specify):
the following parent's name:
h.
Other (specify):
6. Number of pages attached:
Continued on Attachment 5h.
NOTICE: Any party required to pay child support must pay interest on overdue amounts at the "legal" rate,
which is currently 10 percent.
Page 2 of 2
JUDGMENT
(Uniform Parentage—Custody and Support)
FL-250 [Rev. January 1, 2020]
JUDICIAL OFFICER
SIGNATURE FOLLOWS LAST ATTACHMENT
PETITIONER:
RESPONDENT:
CASE NUMBER:
FL-235
Date:
(TYPE OR PRINT NAME)
a.
I have read and understand the Judgment (Uniform Parentage
Custody and Support) (form FL-250) and this Advisement and
Waiver of Rights.
Other
(specify):
I understand the translation.
ADVISEMENT AND WAIVER OF RIGHTS RE:
DETERMINATION OF PARENTAL RELATIONSHIP
(Uniform Parentage)
Form Approved for Optional Use
Judicial Council of California
FL-235 [Rev. January 1, 2020]
Family Code, § 7600 et seq.
www.courts.ca.gov.
Page 1 of 1
ADVISEMENT AND WAIVER OF RIGHTS RE: DETERMINATION OF PARENTAL RELATIONSHIP
RIGHT TO BE REPRESENTED BY A LAWYER. I understand that I have the right to be represented by a lawyer of my
own choice at my own expense. If I cannot afford a lawyer, I can contact the Lawyer Referral Association of the local
bar association or the Family Law Facilitator for assistance.
RIGHT TO A TRIAL. I understand that I have a right to have a judge determine whether I am the parent of the children
named in this action.
RIGHT TO CONFRONT AND CROSS-EXAMINE WITNESSES. I understand that in a trial I have the right to confront
and cross-examine the witnesses against me and to present evidence and witnesses in my own defense.
1.
2.
3.
RIGHT TO HAVE GENETIC TESTING. I understand that, where the law permits, I have the right to have the court
order genetic testing. The court will decide who pays for the tests. The court could order that I pay none, some, or all of
the costs of the tests.
WAIVER. I understand that I am admitting that I am the parent of the children named in the stipulation and am giving
up the rights stated above (except the right to an attorney if I have an attorney).
4.
6.
CHILD SUPPORT. I understand that I will have the duty to contribute to the support of the children named in this
action and that this duty of support will continue for each child until the obligation is terminated by law.
CRIMINAL NON-SUPPORT. I understand that if I willfully fail to support the children, criminal proceedings may be
initiated against me.
5.
OBLIGATIONS. I understand that if I admit that I am the parent of the children in this action that those children will be
my children for legal purposes.
8.
7.
9.
—
UNDERSTANDING.
b.
IF I AM REPRESENTED BY AN
ATTORNEY, I ACKNOWLEDGE THAT MY
ATTORNEY HAS READ AND EXPLAINED
TO ME THE CONTENTS OF THE
STIPULATION, RECITALS, AND WAIVERS,
AND I ACKNOWLEDGE THAT I
UNDERSTAND THEM.
1.
2.
INTERPRETER'S DECLARATION
The
is unable to read or understand the Judgment (Uniform Parentage—Custody and
Support) (form FL-250) and this Advisement and Waiver of Rights because:
a.
b.
I certify under penalty of perjury under the laws of the State of California that I have, to the best of my ability, read or translated for
the
the Judgment (Uniform Parentage—Custody and Support) (form FL-250) and this
Advisement and Waiver of Rights.
understood the Judgment (Uniform Parentage—
Custody and Support) (form FL-250) and this Advisement and Waiver of Rights before signing them, as stated in Item 9 above.
Petitioner Respondent
the primary language of the party is
(specify):
Petitioner
Respondent
Petitioner Respondent
(SIGNATURE OF DECLARANT)
Date:
(TYPE OR PRINT NAME)
(SIGNATURE OF INTERPRETER)
PETITIONER:
RESPONDENT:
CASE NUMBER:
FL-235
Date:
(TYPE OR PRINT NAME)
a.
I have read and understand the Judgment (Uniform Parentage
Custody and Support) (form FL-250) and this Advisement and
Waiver of Rights.
Other
(specify):
I understand the translation.
ADVISEMENT AND WAIVER OF RIGHTS RE:
DETERMINATION OF PARENTAL RELATIONSHIP
(Uniform Parentage)
Form Approved for Optional Use
Judicial Council of California
FL-235 [Rev. January 1, 2020]
Family Code, § 7600 et seq.
www.courts.ca.gov.
Page 1 of 1
ADVISEMENT AND WAIVER OF RIGHTS RE: DETERMINATION OF PARENTAL RELATIONSHIP
RIGHT TO BE REPRESENTED BY A LAWYER. I understand that I have the right to be represented by a lawyer of my
own choice at my own expense. If I cannot afford a lawyer, I can contact the Lawyer Referral Association of the local
bar association or the Family Law Facilitator for assistance.
RIGHT TO A TRIAL. I understand that I have a right to have a judge determine whether I am the parent of the children
named in this action.
RIGHT TO CONFRONT AND CROSS-EXAMINE WITNESSES. I understand that in a trial I have the right to confront
and cross-examine the witnesses against me and to present evidence and witnesses in my own defense.
1.
2.
3.
RIGHT TO HAVE GENETIC TESTING. I understand that, where the law permits, I have the right to have the court
order genetic testing. The court will decide who pays for the tests. The court could order that I pay none, some, or all of
the costs of the tests.
WAIVER. I understand that I am admitting that I am the parent of the children named in the stipulation and am giving
up the rights stated above (except the right to an attorney if I have an attorney).
4.
6.
CHILD SUPPORT. I understand that I will have the duty to contribute to the support of the children named in this
action and that this duty of support will continue for each child until the obligation is terminated by law.
CRIMINAL NON-SUPPORT. I understand that if I willfully fail to support the children, criminal proceedings may be
initiated against me.
5.
OBLIGATIONS. I understand that if I admit that I am the parent of the children in this action that those children will be
my children for legal purposes.
8.
7.
9.
—
UNDERSTANDING.
b.
IF I AM REPRESENTED BY AN
ATTORNEY, I ACKNOWLEDGE THAT MY
ATTORNEY HAS READ AND EXPLAINED
TO ME THE CONTENTS OF THE
STIPULATION, RECITALS, AND WAIVERS,
AND I ACKNOWLEDGE THAT I
UNDERSTAND THEM.
1.
2.
INTERPRETER'S DECLARATION
The
is unable to read or understand the Judgment (Uniform Parentage—Custody and
Support) (form FL-250) and this Advisement and Waiver of Rights because:
a.
b.
I certify under penalty of perjury under the laws of the State of California that I have, to the best of my ability, read or translated for
the
the Judgment (Uniform Parentage—Custody and Support) (form FL-250) and this
Advisement and Waiver of Rights.
understood the Judgment (Uniform Parentage—
Custody and Support) (form FL-250) and this Advisement and Waiver of Rights before signing them, as stated in Item 9 above.
Petitioner Respondent
the primary language of the party is
(specify):
Petitioner
Respondent
Petitioner Respondent
(SIGNATURE OF DECLARANT)
Date:
(TYPE OR PRINT NAME)
(SIGNATURE OF INTERPRETER)
Form Approved for Optional Use
Judicial Council of California
FL-192 [Rev. January 1, 2021]
Family Code, §§ 4062, 4063
NOTICE OF RIGHTS AND RESPONSIBILITIES
Health-Care Costs and Reimbursement Procedures
FL-192
NOTICE OF RIGHTS AND RESPONSIBILITIES
Health-Care Costs and Reimbursement Procedures
IF YOU HAVE A CHILD SUPPORT ORDER THAT INCLUDES A PROVISION FOR THE
REIMBURSEMENT OF A PORTION OF THE CHILD'S OR CHILDREN'S HEALTH-CARE COSTS
AND THOSE COSTS ARE NOT PAID BY INSURANCE, THE LAW SAYS:
1. Notice. You must give the other parent an itemized
statement of the charges that have been billed for any health-
care costs not paid by insurance. You must give this
statement to the other parent within a reasonable time, but no
more than 30 days after those costs were given to you.
2. Proof of full payment. If you have already paid all of the
uninsured costs, you must (1) give the other parent proof that
you paid them and (2) ask for reimbursement for the other
parent's court-ordered share of those costs.
3. Proof of partial payment. If you have paid only your share
of the uninsured costs, you must (1) give the other parent
proof that you paid your share, (2) ask that the other parent
pay his or her share of the costs directly to the health-care
provider, and (3) give the other parent the information
necessary for that parent to be able to pay the bill.
4. Payment by notified parent. If you receive notice from a
parent that an uninsured health-care cost has been incurred,
you must pay your share of that cost within the time the court
orders; or if the court has not specified a period of time, you
must make payment (1) within 30 days from the time you were
given notice of the amount due, (2) according to any payment
schedule set by the health-care provider, (3) according to a
schedule agreed to in writing by you and the other parent, or
(4) according to a schedule adopted by the court.
5. Disputed charges. If you dispute a charge, you may file a
motion in court to resolve the dispute, but only if you pay that
charge before filing your motion. If you claim that the other
party has failed to reimburse you for a payment, or the other
party has failed to make a payment to the provider after proper
notice has been given, you may file a motion in court to resolve
the dispute. The court will presume that if uninsured costs have
been paid, those costs were reasonable. The court may award
attorney fees and costs against a party who has been
unreasonable.
6. Court-ordered insurance coverage. If a parent provides
health-care insurance as ordered by the court, that insurance
must be used at all times to the extent that it is available for
health-care costs.
a.
Burden to prove. The party claiming that the coverage is
inadequate to meet the child's needs has the burden of
proving that to the court.
b. Cost of additional coverage. If a parent purchases health-
care insurance in addition to that ordered by the court, that
parent must pay all the costs of the additional coverage. In
addition, if a parent uses alternative coverage that costs
more than the coverage provided by court order, that parent
must pay the difference.
7. Preferred health providers. If the court-ordered coverage
designates a preferred health-care provider, that provider
must be used at all times consistent with the terms of the
health insurance policy. When any party uses a health-care
provider other than the preferred provider, any health-care
costs that would have been paid by the preferred health
provider if that provider had been used must be the sole
responsibility of the party incurring those costs.
Page 1 of 2
www.courts.ca.
g
o
v
FL-192 [Rev. January 1, 2021]
NOTICE OF RIGHTS AND RESPONSIBILITIES
Health-Care Costs and Reimbursement Procedures
Page 2 of 2
FL-192
INFORMATION SHEET ON CHANGING A CHILD SUPPORT ORDER
General Information
The court has just made a child support order in your case. This order will remain the same unless a party to the action requests that
the support be changed (modified). An order for child support can be modified only by filing a motion to change child support and
serving each party involved in your case. If both parents and the local child support agency (if it is involved) agree on a new child
support amount, you can complete, have all parties sign, and file with the court a Stipulation to Establish or Modify Child Support and
Order ( ) or Stipulation and Order (Governmental) ( ).
When a Child Support Order May Be Modified
The court takes several things into account when ordering the payment of child support. First, the number of children is considered.
Next, the net incomes of both parents are determined, along with the percentage of time each parent has physical custody of the
children. The court considers both parties’ tax filing status and may consider hardships, such as a child of another relationship. An
existing order for child support may be modified when the net income of one of the parents changes significantly, the parenting
schedule changes significantly, or a new child is born.
Examples
•
You have been ordered to pay $500 per month in child support. You lose your job. You will continue to owe $500 per month, plus
10 percent interest on any unpaid support, unless you file a motion to modify your child support to a lower amount and the court
orders a reduction.
•
You are currently receiving $300 per month in child support from the other parent, whose net income has just increased
substantially. You will continue to receive $300 per month unless you file a motion to modify your child support to a higher amount
and the court orders an increase.
•
You are paying child support based upon having physical custody of your children 30 percent of the time. After several months it
turns out that you actually have physical custody of the children 50 percent of the time. You may file a motion to modify child
support to a lower amount.
How to Change a Child Support Order
To change a child support order, you must file papers with the court. Remember: You must follow the order you have now.
What forms do I need?
If you are asking to change a child support order, you must fill out one of these forms:
•
, Request for Order or
•
, Notice of Motion and Motion for Simplified Modification of Order for Child, Spousal, or Family Support
You must also fill out one of these forms:
•
, Income and Expense Declaration or
•
, Financial Statement (Simplified)
What if I am not sure which forms to fill out?
Talk to the family law facilitator at your court.
After you fill out the forms, file them with the court clerk and ask for a hearing date. Write the hearing date on the form.
The clerk may ask you to pay a filing fee. If you cannot afford the fee, fill out these forms, too:
•
, Request to Waive Court Fees
•
, Order on Court Fee Waiver (Superior Court)
You must serve the other parent. If the local child support agency is involved, serve it too.
This means someone 18 or over—not you—must serve the other parent copies of your filed court forms at least 16 court days before
the hearing. Add 5 calendar days if you serve by mail within California (see Code of Civil Procedure section 1005 for other situations).
Court days are weekdays when the court is open for business (Monday through Friday except court holidays). Calendar days include
all days of the month, including weekends and holidays. To find court holidays, go to .
The server must also serve blank copies of these forms:
•
, Responsive Declaration to Request for Order and , Income and Expense Declaration,or
•
, Financial Statement (Simplified)
Then the server fills out and signs a Proof of Service ( or ). Take this form to the clerk and file it.
Go to your hearing and ask the judge to change the support. Bring your tax returns from the last two years and your last two
months' pay stubs. The judge will look at your information, listen to both parents, and make an order. After the hearing, fill out:
•
, Findings and Order After Hearing and
•
, Child Support Information and Order Attachment
Need help?
Contact the in your county or call your county's bar association and ask for an experienced family lawyer.
form FL-350
form FL-625
Form FL-300
Form FL-390
Form FL-150
Form FL-155
Form FW-001
Form FW-003
www.courts.ca.gov/holida
y
s.htm
Form FL-320
form FL-150
Form FL-155
form FL-330
form FL-335
Form FL-340
Form FL-342
famil
y
law facilitato
r
d.
a.
(name):
will be as follows:
The parties will go to child custody mediation or child custody recommending counseling at (specify date, time, and
No Visitation (Parenting Time)
Visitation (Parenting Time) for the
petitioner
respondent other
location):
-page document 6HHWKHDWWDFKHG
b.
c.
e.
Reasonable right of visitation to the party without physical custody (not appropriate in cases involving domestic
violence)
(1)
at
(day of week) (time)
from
1st 2nd 3rd 4th 5th weekend of the month
p.m./ if applicable, specify:a.m.
at
(day of week) (time)
to
a.m.
p.m./ if applicable, specify:
after school
start of school
after school
start of school
(Note: The first weekend of the month is the first weekend with a Saturday.)
(date):
Weekends starting
(b)
(a)
having the initial fifth weekend, which starts (date):
The parties will alternate the fifth weekends, with the
other parent/party
respondent
petitioner
even numbered months.odd
The other parent/partyrespondentpetitioner will have the
CHILD CUSTODY AND VISITATION (PARENTING TIME)
ORDER ATTACHMENT
Family Code, §§ 3020, 3022, 3025,
3040–3043, 3048, 3100, 6340, 7604
www.courts.ca.gov
Form Approved for Optional Use
Judicial Council of California
FL-341 [Rev. July 1, 2016]
5.
7.
Page 1 of 3
Penalties for violating this order. If you violate this order, you may be subject to civil or criminal penalties, or both.
4.
6.
THIS IS A COURT ORDER.
CHILD CUSTODY AND VISITATION (PARENTING TIME) ORDER ATTACHMENT
TO
Stipulation and Order fo Custody and/or Visitation of Children (form FL-355)
Findings and Order After Hearing (form FL-340) Judgment (form FL-180) Judgment (form FL-250)
2WKHUVSHFLI\
1.
2.
Jurisdiction. This court has jurisdiction to make child custody orders in this case under the Uniform Child Custody Jurisdiction and
Enforcement Act (Fam. Code, §§ 3400–3465).
Notice and opportunity to be heard. The responding party was given notice and an opportunity to be heard, as provided by the
laws of the State of California.
3. Country of habitual residence. The country of habitual residence of the child or children in this case is
(specify):
2WKHU
WKH8QLWHG6WDWHV
Child Custody. Custody of the minor children of the parties is awarded as follows:
Child abduction prevention. There is a risk that one of the parties will take the children out of California without the other
party's permission. (Child Abduction Prevention Orders Attachment (form FL-341(B)) must be attached and must be obeyed.)
Visitation (Parenting Time)
Child's Name
Legal custody to: (person who makes
decisions about health, education, etc.)
Birth Date
Physical custody to:
(person with whom child lives)
FL-341
CASE NUMBER:
PETITIONER:
RESPONDENT:
OTHER PARENT/PARTY:
fifth weekend in
✖
✖
✖
10.
a.
c.
b.
(specify):
the state of California.
the following counties
other places
(specify):
9.
b.
c.
d.
a.
(address):
(specify):
Transportation to begin the visits will be provided by the
Transportation from the visits will be provided by the
The exchange point at the beginning of the visit will be at
The exchange point at the end of the visit will be at
During the exchanges, the party driving the children will wait in the car and the other party will wait in his or her
home (or exchange location) while the children go between the car and the home (or exchange location).
Other (specify):
other
respondentpetitioner
(address):
(specify):
other
respondentpetitioner
The children must be driven only by a licensed and insured driver. The car or truck must have legal child restraint
devices.
f.
g.
e.
8.
(specify):
FL-341 [Rev. July 1, 2016]
(You must attach Supervised Visitation Order (form FL-341(A).)
must have written permission from the other parent or a court order to take the children out of
The
(name):
will have supervised visitation (parenting time) with the minor children according to the schedule set forth on page 1.
(2)
Alternate weekends starting
(date):
at
(day of week) (time)
from
a.m.
p.m./ if applicable, specify:
at
(day of week)
to a.m.
p.m./ if applicable, specify:
after school
start of school
after school
start of school
after school
start of school
after school
start of school
(time)
(3)
(date):
Weekdays starting
at
(day of week) (time)
from
at
(day of week) (time)
to
(4)
Other visitation (parenting time) days and restrictions are:
listed in Attachment 7e(4) (form
as follows:
MC-025 may be used for this purpose)
p.m./ if applicable, specify:
a.m.
a.m.
p.m./ if applicable, specify:
e.
Visitation (Parenting Time) (continued)
Supervised visitation (parenting time). Until
Transportation for visitation (parenting time)
further order of the court other
other
respondentpetitioner
Travel with children. The
petitioner respondent other parent/party
(name):
CHILD CUSTODY AND VISITATION (PARENTING TIME)
ORDER ATTACHMENT
Page 2 of 3
THIS IS A COURT ORDER.
FL-341
CASE NUMBER:
PETITIONER:
RESPONDENT:
OTHER PARENT/PARTY:
7.
12.
13.
15.
attached schedule. (Additional Provisions—Physical Custody Attachment (form FL-341(D)
) may be used for this purpose.)
(Joint Legal Custody Attachment (form FL-341(E)
) may be used for this purpose.)
11. The children will spend holiday time as listed
Holiday Schedule Attachment (form FL-341(C)
) may be used for this purpose.)
Other (specify):
FL-341 [Rev. July 1, 2016]
CHILD CUSTODY AND VISITATION (PARENTING TIME)
ORDER ATTACHMENT
Page 3 of 3
THIS IS A COURT ORDER.
Holiday schedule.
EHORZ
LQWKHDWWDFKHGVFKHGXOH&KLOGUHQV
The parties will follow the additional custody provisions listed
Additional custody provisions.
EHORZ LQWKH
The parties will share joint legal custody as listedJoint legal custody.
LQWKHDWWDFKHGVFKHGXOHEHORZ
14. Access to children's records. Both the custodial and noncustodial parent have the right to access records and information
about their minor children (including medical, dental, and school records) and consult with professionals who are providing services
to the children.
FL-341
CASE NUMBER:
PETITIONER:
RESPONDENT:
OTHER PARENT/PARTY:
FL-342
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT/PARTY:
CASE NUMBER:
CHILD SUPPORT INFORMATION AND ORDER ATTACHMENT
TO
THE COURT USED THE FOLLOWING INFORMATION IN DETERMINING THE AMOUNT OF CHILD SUPPORT:
1.
2.
Gross monthly
income
Net monthly
income
Receiving
TANF/CaIWORKS
Each parent’s monthly income is as follows:
Imputation of income. The court finds that the
and has based the support order upon this imputed income.
3.
%
%
4.
Hardships for the following have been allowed in calculating child support:
Petitioner/
plaintiff
Respondent/
defendant
Approximate ending time
for the hardship
a.
b.
c.
THE COURT ORDERS
5.
6.
a. Base child support
(date): and continuing until further order of the court, or until the child marries, dies, is emancipated, reaches
age 19, or reaches age 18 and is not a full-time high school student, whichever occurs first, as follows:
Payable to (name):
Date of birth Monthly amount
Payable
Child’s name
%
must pay child support beginning
has the capacity to earn:
a.
b.
Other parent/
party
a.
b.
Petitioner/plaintiff: $
Respondent/defendant: $
Other parent/party: $
$
$
$
$
$
$
$
$
$
$
$
$
Number of children who are the subjects of the support order (specify):
Approximate percentage of time spent with petitioner/plaintiff:
Respondent/defendant:
Other parent/party:
The low-income adjustment applies.
Other minor children:
Extraordinary medical expenses:
Catastrophic losses:
Child support
Petitioner/plaintiff
Respondent/defendant Other parent/party
Petitioner/plaintiff
Respondent/defendant
Other parent/party
Hardships
Children of this relationship
Income
Low-income adjustment
Findings and Order After Hearing (form FL-340)
Restraining Order After Hearing (CLETS-OAH) (form DV-130)
Judgment (form FL-180)
$
per
(specify):
on the 1st of the month
Other
a.
b.
other (specify):
7KHORZLQFRPHDGMXVWPHQWGRHVQRWDSSO\EHFDXVHVSHFLI\UHDVRQV
Judgment (form FL-250)
A printout of a computer calculation and findings is attached and incorporated in this order for all required items not filled out
below.
one-half on the 1st and one-half on the 15th of the month
THIS IS A COURT ORDER.
Page 1 of 3
CHILD SUPPORT INFORMATION AND ORDER ATTACHMENT
Form Adopted for Mandatory Use
Judicial Council of California
FL-342 [Rev. January 1, 2020]
Family Code, §§ 4055-4069
www.courts.ca.gov
✖
✖
Page 2 of 3
THIS IS A COURT ORDER.
This order does not meet the child support guideline set forth in Family Code section 4055. Non-Guideline Child Support
Findings Attachment ( ) is attached.
(1)
(2)
their respective places of employment or self-employment. Both parties are ordered to cooperate in the presentation, collection,
and reimbursement of any health-care claims. 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.
d.
7. Health-care expenses
Health insurance coverage for the minor children of the parties must be maintained by the
a.
per month.
per month.
per month.
per month.
per month.
per month.
if available at no or reasonable cost through
(2)
Reasonable uninsured health-care costs for the children
per month.
per month.
per month.
Mandatory additional child support
THE COURT FURTHER ORDERS
per month child-care costs.
(d)
(c)
6.
(1)
Child-care costs related to employment or reasonably necessary job training
per month
per month
child-care costs.
child-care costs.
(a)
(b)
e.
Total child support per month: $
$
$
$
$
$
$
$
$
$
$
$
$
Mandatory additional child support
Additional child support
Non-Guideline Order
Petitioner/plaintiff must pay:
Respondent/defendant must pay:
Other parent/party must pay:
Costs to be paid as follows
(specify):
(d)
(c)
(a)
(b)
Petitioner/plaintiff must pay:
Respondent/defendant must pay:
Other parent/party must pay:
Costs to be paid as follows
(specify):
(d)
(c)
(a)
(b)
Petitioner/plaintiff must pay:
Respondent/defendant must pay:
Other parent/party must pay:
Costs to be paid as follows
(specify):
(d)
(c)
(a)
(b)
Petitioner/plaintiff must pay:
Respondent/defendant must pay:
Other parent/party must pay:
Costs to be paid as follows
(specify):
Costs related to the educational or other special needs of the children
Travel expenses for visitation
petitioner/plaintiff
respondent/defendant other parent/party
% of total or
% of total or
% of total or
% of total or
% of total or
% of total or
% of total or
% of total or
% of total or
% of total or
% of total or
% of total or
b.
c.
at a reasonable cost at this time.
petitioner/plaintiff
respondent/defendant other parent/party
The party providing coverage must assign the right of reimbursement to the other party.
Health insurance is not available to the
8.
Earnings assignment
An earnings assignment order is issued. Note: The payor of child support is responsible for the payment of support directly to the
recipient until support payments are deducted from the payor’s wages and for payment of any support not paid by the assignment.
c.
b.
CHILD SUPPORT INFORMATION AND ORDER ATTACHMENT
FL-342 [Rev. January 1, 2020]
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT/PARTY:
CASE NUMBER:
FL-342
form FL-342
(
A
)
Page 3 of 3
THIS IS A COURT ORDER.
Notices
a.
Notice of Rights and Responsibilities (Health-Care Costs and Reimbursement Procedures) and Information Sheet on Changing
a Child Support Order ( ) must be attached and is incorporated into this order.
Child Support Case Registry Form
Both parties must complete and file with the court a Child Support Case Registry Form ( ) within 10 days of the date of
this order. Thereafter, the parties must notify the court of any change in the information submitted within 10 days of the change by
filing an updated form.
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.
11.
12.
13.
If this form is attached to Restraining Order After Hearing ( ), the support orders issued on this form (form FL-342)
remain in effect after the restraining orders issued on form DV-130 end.
b.
is ordered to seek employment with the
following terms and conditions:
Petitioner/plaintiff Other parent/party
Respondent/defendant
Employment search order (Family Code § 4505)
10.
9.
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 of past due support 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.
Other orders (specify):
CHILD SUPPORT INFORMATION AND ORDER ATTACHMENT
FL-342 [Rev. January 1, 2020]
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT/PARTY:
CASE NUMBER:
FL-342
form FL-191
form FL-19
2
form DV130
FL-190
FOR COURT USE ONLY
PETITIONER:
RESPONDENT:
CASE NUMBER:
NOTICE OF ENTRY OF JUDGMENT
You are notified that the following judgment was entered on (date):
1. Dissolution
2. Dissolution—status only
Dissolution—reserving jurisdiction over termination of marital status or domestic partnership
3.
4. Legal separation
Nullity
5.
Parent-child relationship6.
7.
Judgment on reserved issues
Other (specify):
8.
Date:
Clerk, by
, Deputy
—NOTICE TO ATTORNEY OF RECORD OR PARTY WITHOUT ATTORNEY—
Under the provisions of Code of Civil Procedure section 1952, if no appeal is filed the court may order the exhibits destroyed or
otherwise disposed of after 60 days from the expiration of the appeal time.
I certify that I am not a party to this cause and that a true copy of the Notice of Entry of Judgment was mailed first class, postage
fully prepaid, in a sealed envelope addressed as shown below, and that the notice was mailed
Effective date of termination of marital or domestic partnership status (specify):
WARNING: Neither party may remarry or enter into a new domestic partnership until the effective date of the termination
of marital or domestic partnership status, as shown in this box.
CLERK’S CERTIFICATE OF MAILING
Date:
Clerk, by
, Deputy
Page 1 of 1
NOTICE OF ENTRY OF JUDGMENT
(Family Law—Uniform Parentage—Custody and Support)
Family Code, §§ 2338, 7636,7637
Form Adopted for Mandatory Use
Judicial Council of California
FL-190 [Rev. January 1, 2005]
at (place):
on (date):
, California,
www.courtinfo.ca.gov
STATEMENT IN THIS BOX APPLIES ONLY TO JUDGMENT OF DISSOLUTION
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
Name and address of petitioner or petitioner's attorney Name and address of respondent or respondent's attorney
TELEPHONE NO.:
ATTORNEY FOR (Name):
FAX NO. (Optional):
E-MAIL ADDRESS (Optional):
ORANGE
341 THE CITY DRIVE
ORANGE, CA 92868
LAMOREAUX JUSTICE CENTER
X
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:
$
ORANGE
341 THE CITY DRIVE
Post Office Box 14710
Oran
g
e, CA 92868
Lamoreaux Justice Center
✔
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.
Additional 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)
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:
$
ORANGE
341 THE CITY DRIVE
Post Office Box 14710
Oran
g
e, CA 92868
Lamoreaux Justice Center
✔
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.
Additional 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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Self-Help Services SUPERIOR COURT OF CALIFORNIA www.occourts.orgself-help COUNTY (The Superior Court of California - County of Orange)

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Completed 8 February 2021

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