FL-490 PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT/PARTY: CASE NUMBER: APPLICATION TO DETERMINE ARREARS Attachment to Request for Order (form FL-300) Child support Unreimbursed expenses Other (specify): 1. I ask that the amount of past due support payments (arrears) be decided in this case. 2. I have attached (check all that apply): a. a Declaration of Payment History (FL-420) b. a Payment History Attachment (FL-421) c. Other (specify): Spousal or partner support Family support Medical support Unreimbursed medical expenses 3. a. b. I ask that the amount of past due support payments (arrears) be decided in this case. I have already paid all of the support ordered. Proof of payment is attached. some The children for whom support is to be paid were living with me full time for the period from . I provided all of their support during that period. I am attaching a detailed declaration to: explaining these facts and supporting documentation, including any proof that the children were living with me. Suspended due to jail, prison, or an Institution (juvenile facility or mental health facility). (Family Code, § 4007.5) (1) I was incarcerated or involuntarily institutionalized for the following periods for more than 90 days in a row during which I did not have the financial ability to pay child support. (Attach any proof of your incarceration or involuntary institutionalization.) (a) Date(s) incarceration or involuntary institutionalization began: (b) Date(s) incarceration or involuntary institutionalization ended: (2) (3) d. The reason that I was in jail, prison, or an institution (juvenile facility or mental health facility) was not because I failed to pay court ordered child support or committed domestic violence against the supported person or child. My child support order was made or changed by the court on or after October 8, 2015. Other (specify): c. 4. I have previously asked the other parent for payment and provided the other parent with an itemized statement of the unreimbursed childcare expense medical expense. (Attach copies of all bills being claimed and proof of any payments that you have made on these bills.) I am asking the other person to pay a. Attorney Fees b. Income and Expense Declaration (form FL-150) is attached. contained in the attached declaration. Costs. 5. 6. Facts in support of the relief requested are (specify): 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 DECLARANT) Petitioner/Plaintiff Attorney Respondent/Defendant Other (specify): NOTICE: This form must be attached to Request for Order (FL-300) NOT A COURT ORDER Form Adopted for Mandatory Use Judicial Council of California FL-490 [Rev. January 1, 2017] Page of APPLICATION TO DETERMINE ARREARS Family Code, §§ 4007.5, 4720-4732 www.courts.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com