FL-401 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and address): TELEPHONE NO.: FOR COURT USE ONLY ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: CASE NUMBER: APPLICATION FOR DISBURSEMENT AND ORDER FOR DISBURSEMENT FROM CHILD SUPPORT SECURITY DEPOSIT APPLICATION FOR DISBURSEMENT FROM CHILD SUPPORT SECURITY DEPOSIT 1. The undersigned is entitled to receive child support payments. A deposit has been established to secure payment of the child support. The support is more than 10 days late, as follows: Amount due Date due Amount paid Amount due as child support Total amount due: 2. I request that the court order disbursement of the amount due from the child support security deposit. 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) A copy of this application must be served on the obligor and proof of its service attached to the original that is filed with the court. ORDER FOR DISBURSEMENT FROM CHILD SUPPORT SECURITY DEPOSIT AND ORDER TO REPLENISH FUNDS 3. The following financial institution (name): must pay the following amount: $ support (name): to the following person who is entitled to receive payment of child 4. The obligor (name): must replenish the child support security deposit by depositing the following amount: $ not later than (date): The original evidence of replenishment must be filed with the court. A copy of the evidence of replenishment must be served on the person entitled to receive payment of the child support. Date: JUDGE OF THE SUPERIOR COURT 5. I certify that the foregoing order is a copy of the original on file with the court. Date: Form Adopted for Mandatory Use Judicial Council of California FL-401 [Rev. January 1, 2003] Clerk, by , Deputy Page 1 of 1 Family Code, §§ 4570­4573 www.courtinfo.ca.gov 2002 © American LegalNet, Inc. APPLICATION FOR DISBURSEMENT AND ORDER FOR DISBURSEMENT FROM CHILD SUPPORT SECURITY DEPOSIT