FL-643
ATTORNEY OR PARTY WITHOUT ATTORNEY OR GOVERNMENTAL AGENCY (Name, State Bar number, and address): 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:
DECLARATION OF OBLIGOR'S INCOME DURING JUDGMENT PERIOD-- PRESUMED INCOME SETASIDE REQUEST
I, (name): 1. I am
CASE NUMBER:
declare that: the obligor (parent required to pay support). a representative of the local child support agency providing support services in this matter. other (specify): a Judgment Regarding Parental Obligations (form FL-630) was entered using presumed
2. On (date): income.
3. Information concerning the obligor's income and other factors relevant to calculating the correct support for the time periods in the judgment follow: Obligor's Monthly % Of Time Source of Guideline Time Period Average With Children Income Support Monthly Income (if known) Month/Year (start and end) Information Requested a. b. c. d. e. f. g. h. i. 4. $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Additional evidence regarding the obligor's actual income is attached. (Black out your social security number from any papers, such as pay stubs, that you attach.)
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) Form Approved for Optional Use Judicial Council of California FL-643 [New January 1, 2007]
(SIGNATURE OF DECLARANT)
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DECLARATION OF OBLIGOR'S INCOME DURING JUDGMENT PERIOD-- PRESUMED INCOME SETASIDE REQUEST
(Governmental)
Family Code, §§ 2330.1, 17400, 17428, 17430, 17432 www.courtinfo.ca.gov American LegalNet, Inc. www.FormsWorkflow.com