FL-687 FOR COURT USE ONLY GOVERNMENTAL AGENCY (Under Family Code, §§ 17400,17406): TELEPHONE NO. (Optional): 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: CASE NUMBER: ORDER AFTER HEARING 1. This matter proceeded as follows: a. Date: Dept.: Petitioner/plaintiff present b. c. d. e. f. Uncontested By stipulation Judicial officer: Attorney present (name): Contested Respondent/defendant present Attorney present (name): Other parent present Attorney present (name): Local child support agency attorney (Family Code, §§ 17400, 17406) by (name): Other (specify): g. The parent ordered to pay support is the petitioner/plaintiff respondent/defendant other parent 2. Attached is a computer printout showing the parents’ income 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. This order is based on the attached documents (specify): 3. THE COURT ORDERS 4. a. All orders previously made in this action remain in full force and effect except as specifically modified below. b. The parent ordered to pay support is the parent of and must pay current child support for the following children: Name of child Date of birth Monthly support amount (1) Mandatory additional child support (a) The parent ordered to pay support must pay additional monthly support for reasonable child-care costs, as follows one-half or % or (specify amount): $ per month of the costs. State Disbursement Unit Payments must be made to the other parent child-care provider. (b) The parent ordered to pay support must pay reasonable uninsured health-care costs for the children, as follows: one-half or % or (specify amount): $ per month of the costs. Payments must be made to the other parent State Disbursement Unit health-care provider. 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 Form Adopted for Alternative Mandatory Use Instead of Form FL-692 Judicial Council of California FL-687 [Rev. July 1, 2011] ORDER AFTER HEARING (Governmental) Family Code, §§ 17402, 17404,17400 www.courts.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com FL-687 PETITIONER/PLAINTIFF: CASE NUMBER: RESPONDENT/DEFENDANT: OTHER PARENT: 4. b. (2) Other (specify): (3) For a total of $ beginning (date): (4) The low-income adjustment applies. The low-income adjustment does not apply because (specify reasons): payable on the day of each month (5) Any support ordered will continue until further order of court, unless terminated by operation of law. (6) As provided in Family Code section 4007.5, the obligation of the person ordered to pay support will be temporarily suspended for any period after the first 90 consecutive days in which the person ordered to pay support is incarcerated or involuntarily institutionalized, unless that person has the ability to pay support during that time or has committed certain crimes. Immediately after the person ordered to pay support is released from incarceration or involuntary institutionalization, the support order will restart in the same amount as it was before it was temporarily suspended. The parent receiving support must (1) provide and maintain health insurance The parent ordered to pay support c. coverage for the children if available at no or reasonable cost and keep the local child support agency informed of the availability of the coverage (the cost is presumed to be reasonable if it does not exceed 5% of gross income to add a child); (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; and (6) assign any rights to reimbursement to the other parent or caretaker who incurs costs for health-care services for the children. 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. The parent ordered to pay support owes support arrears as follows, as of (date): (1) Child support: $ Spousal support: $ Family support: $ (2) Interest is not included and is not waived. (3) day of each month Payable: $ on the beginning (date): Interest accrues on the entire principal balance owing and not on each installment as it becomes due. (4) e. No provision of this order 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. f. All payments, unless specified in item 4b(1) above, must be made to the State Disbursement Unit at the address listed below (specify address): g. An earnings assignment order is issued. h. 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. i. If “The parent ordered to pay support” box is checked in item 4c, a health insurance coverage assignment must issue. FL-687 [Rev. July 1, 2011] ORDER AFTER HEARING (Governmental) Page 2 of 3 FL-687 PETITIONER/PLAINTIFF: CASE NUMBER: RESPONDENT/DEFENDANT: OTHER PARENT: 4. j. k. The parents must notify the local child support agency in writing within 10 days of any change in residence or employment. 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. l. The following person (the “other parent”) is added as a party to this action (name): m. The court further orders (specify): Date: JUDICIAL OFFICER Number of pages attached: SIGNATURE FOLLOWS LAST ATTACHMENT Approved as conforming to court order. Date: (SIGNATURE OF ATTORNEY FOR THE PARENT ORDERED TO PAY SUPPORT) FL-687 [Rev. July 1, 2011] ORDER AFTER HEARING (Governmental) Page 3 of 3