Free FL-625 Stipulation and Order (Governmental) - California

FL-625
GOVERNMENTAL AGENCY (under Family Code, §§ 17400,17406): FOR COURT USE ONLY

TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME:

PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT:

STIPULATION AND ORDER
1. This matter proceeded as follows: a. b. By written stipulation without court appearance. By court hearing, appearances as follows: Dept.: Judicial officer: (1) Date: Petitioner/plaintiff present Attorney present (name): (2) Attorney present (name): Respondent/defendant present (3) (4) Other parent present Attorney present (name): (5) Local child support agency (Family Code, §§ 17400, 17406) by (name): (6) Other (specify): petitioner/plaintiff

CASE NUMBER:

c. The obligor (the parent ordered to pay support) is the 2. This order is based on the attached documents (specify):

respondent/defendant

other parent.

3. The parties agree that a. all orders previously made in this action remain in full force and effect except as specifically modified below. per month. b. the amount of support payable by obligor as calculated under the guideline is: $ We agree to guideline support. The guideline amount should be rebutted because of the following: We have been fully informed of the guideline amount of support; we agree voluntarily to child support of: (1) per month; the agreement is in the best interest of the children; the needs of the children $ will be met adequately by the agreed amount; the children are not receiving public assistance; no application for public assistance is pending; and application of the guideline would be unjust and inappropriate in this case. We understand that if the order is below the guideline, no change of circumstances need be shown to raise this order to the guideline amount. If the order is above the guideline, a change of circumstances will be required to modify this order. (2) Other rebutting factors (specify):

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.
Page 1 of 3 Family Code, §§ 17400, 17402, 17404, 17430 www.courtinfo.ca.gov American LegalNet, Inc. www.FormsWorkflow.com

Form Adopted for Alternative Mandatory Use Instead of Form FL-692 Judicial Council of California FL-625 [Rev. January 1, 2009]

STIPULATION AND ORDER
(Governmental)

FL-625
PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT:
CASE NUMBER:

3. c.

Attached is a computer printout showing the parents' incomes and percentage of time each parent spends with the children. The printout, which shows the calculation of child support payable, will become the court's findings. d. Obligor must pay current child support as follows: Name Date of birth Monthly support amount

(1)

Other (specify):

(2) (3)

For a total of: $ beginning (date):

payable on the:

day of each month

The low-income adjustment applies. The low-income adjustment does not apply because (specify reasons):

(4) Any support ordered will continue until further order of court, unless terminated by operation of law. e. Obligor owes support arrears as follows, as of (date): (1) (2) (3) (4) f. Spousal support: $ Family support: $ Child support: $ Interest is not included and is not waived. Payable: $ on the: day of each month beginning (date): Interest accrues on the entire principal balance owing and not on each installment as it becomes due.

No provision of this judgment may operate to limit any right to collect the principal (total amount of unpaid support) or to charge and collect interest and penalties as allowed by law. All payments ordered are subject to modification.

g. All payments must be made to (name and address of agency):

h. An Income Withholding for Support (form FL-195/OMB No. 0970-0154) will issue. i. Obligor Obligee must (1) provide and maintain health insurance coverage for the children if it is available

through employment or a group plan, or otherwise available at no or reasonable cost, and must keep the local child support agency informed of the availability of the coverage; (2) if health insurance is not available, provide coverage when it becomes available; (3) within 20 days of the local child support agency's request, complete and return a health insurance form; (4) provide to the local child support agency all information and forms necessary to obtain health-care services for the children; (5) present any claim to secure payment or reimbursement to the other parent or caretaker who incurs costs for health-care services for the children; (6) assign any rights to reimbursement to the other parent or caretaker who incurs costs for health-care services for the children. If the "Obligor" box is checked, a health insurance coverage assignment will issue. j. will issue The parents must notify the local child support agency in writing within 10 days of any change in residence or employment. k. The 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.
FL-625 [Rev. January 1, 2009]

STIPULATION AND ORDER
(Governmental)

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FL-625
PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT:
CASE NUMBER:

3.

I. m.

The following person (the "other parent") is added as a party to this action under Family Code section 17404 (name): Other (specify):

Date:
(TYPE OR PRINT NAME) (SIGNATURE OF ATTORNEY FOR LOCAL CHILD SUPPORT AGENCY)

Date:

(TYPE OR PRINT NAME)

(SIGNATURE OF PETITIONER)

Date:

[TYPE OR PRINT NAME)

(SIGNATURE OF ATTORNEY FOR PETITIONER)

Date:

(TYPE OR PRINT NAME)

(SIGNATURE OF RESPONDENT)

Date:

(TYPE OR PRINT NAME)

(SIGNATURE OF ATTORNEY FOR RESPONDENT)

Date:
(TYPE OR PRINT NAME) (SIGNATURE OF OTHER PARENT)

Date:

(TYPE OR PRINT NAME)

(SIGNATURE OF ATTORNEY FOR OTHER PARENT)

ORDER
4. THE COURT SO ORDERS. Date:
JUDICIAL OFFICER

5. Number of pages attached:

SIGNATURE FOLLOWS LAST ATTACHMENT

DECLARATION OF PERSON PROVIDING INTERPRETATION/TRANSLATION: The party/parties indicated below is/are unable to read or understand this Stipulation and Order because (Insert name) __________________________'s primary language is (specify): (Insert name)__________________________'s primary language is (specify):

and he or she and he or she has has has not read the form has not read the form stipulation translated into this language. stipulation translated into this language. I certify under penalty of perjury under the laws of the State of California that I am competent to interpret or translate in the primary language indicated above and that I have, to the best of my ability, read to, interpreted for, or translated for the above-named party the Stipulation and Order in the party's primary language. The above-named party said he or she understood the terms of this Stipulation and Order before signing it. Date: Date:
(TYPE OR PRINT NAME) (TYPE OR PRINT NAME)

(SIGNATURE) FL-625 [Rev. January 1, 2009]

(SIGNATURE)

STIPULATION AND ORDER
(Governmental)

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