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) Page 1 of 1 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