FL-676 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: OTHER PARENT: REQUEST FOR JUDICIAL DETERMINATION OF SUPPORT ARREARAGES CASE NUMBER: NOTICE OF HEARING 1. A hearing on this application will be held as follows (see instructions on how to get a hearing date): a. Date: Time: b. Address of court: same as noted above Dept.: Div.: Room: other (specify): 2. The local child support agency is providing support enforcement services in this case. 3. The local child support agency states that I owe support arrearages as shown in the attached document. 4. I disagree with the local child support agency's statement, and I request the court to make a determination of arrearages. I am attaching my statement of the arrearages which includes a monthly breakdown of amounts ordered and amounts paid. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: (SIGNATURE) (TYPE OR PRINT NAME) This case may be referred to a court commissioner for hearing. By law, court commissioners do not have the authority to issue final orders and judgments in contested cases unless they are acting as temporary judges. The court commissioner in your case will act as a temporary judge unless, before the hearing, you or any other party objects to the commissioner acting as a temporary judge. The court commissioner may still hear your case to make findings and recommendations to a judge. However, if you object to the commissioner acting as a temporary judge, an order will not be made until a judge reviews your case. Page 1 of 3 Form Adopted for Mandatory Use Judicial Council of California FL-676 [Rev. January 1, 2003] REQUEST FOR JUDICIAL DETERMINATION OF SUPPORT ARREARAGES (Governmental) Family Code, 17526 www.courtinfo.ca.gov. 2003 © American LegalNet, Inc. PETITIONER/PLAINTIFF: CASE NUMBER: RESPONDENT/DEFENDANT: OTHER PARENT: An adult other than you must complete the Proof of Service below and provide a copy of this request to the local child support agency at the following address (specify): PROOF OF SERVICE 5. At the time of service I was at least 18 years of age and not a party to the legal action. 6. My residence or business address is (specify): 7. I served this request and any other forms filed with the request on the local child support agency. a. Personal delivery. I personally delivered this request to an employee of the local child support agency as follows: (1) Name of employee: (2) Address where delivered: (3) Date of delivery: (4) Time of delivery: b. Mail. I deposited this request in the United States mail, in a sealed envelope with postage fully prepaid. I used first class mail. The envelope was addressed and mailed as follows: (1) Name: (2) Address: (3) Date of mailing: (4) Place of mailing (city and state): I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: (SIGNATURE OF PERSON WHO SERVED REQUEST) (TYPE OR PRINT NAME) Page 2 of 3 FL-676 [Rev. January 1, 2003] REQUEST FOR JUDICIAL DETERMINATION OF SUPPORT ARREARAGES (Governmental) 2003 © American LegalNet, Inc. INFORMATION SHEET FOR REQUEST FOR JUDICIAL DETERMINATION OF SUPPORT ARREARAGES Please follow these instructions to complete a Request for Judicial Determination of Support Arrearages (form FL-676) if you do not have an attorney to represent you. Your attorney, if you have one, should complete this form. This form should be used only if you disagree with the support arrearages that the local child support agency says that you owe and you cannot reach an agreement with the local child support agency. When you have completed this form, file the original and attachments with the court clerk. The address of the court clerk is listed in the telephone directory under "County Government Offices." You may have to pay a filing fee. If you cannot afford to pay the filing fee, the court may waive it. For more information about the filing fee and waiver of the filing fee, contact the court clerk. Keep two copies of the filed Request for Judicial Determination of Support Arrearages form and its attachments. Serve one copy on the local child support agency and keep the other for your records. (See Information Sheet for Service of Process, form FL-611.) INSTRUCTIONS FOR COMPLETING THE REQUEST FOR JUDICIAL DETERMINATION OF SUPPORT ARREARAGES FORM (TYPE OR PRINT FORM IN BLACK INK): Front page, first box, top of form, left side: Print your name, address, and telephone number in this box if it is not already there. Front page, second box, left side: Print your county's name and the court's address in the box. Use the same address for the court that is on your most recent support order or judgment. If you do not have a copy of your most recent support order or judgment, you can get one from either the court clerk or the local child support agency. Front page, third box, left side: Print the names of the Petitioner/Plaintiff, Respondent/Defendant, and Other Parent in this box. Use the same names listed in your most recent support order or judgment. If no name is listed for the Other Parent leave that line blank. Front page, first box, top of form, right side: Leave this box blank for the court's use. Front paqe, second box, right side: Print your case number in this box. This number is also listed on your most recent support order or judgment. 1.a.-b. You must contact the court clerk's office and ask that a hearing date be set for this motion. The court clerk will give you the information you need to complete this section. 2. This section states that the local child support agency is handling your support case. 3. This section requires you to attach the statement or other document from the local child support agency that tells the amount of your support 4. This section requires you to attach your own statement of the amount of your support arrearage. Your statement must show a monthly breakdown of the amount of support ordered and the amount you paid each month. You must date the request, print your name and sign the form under penalty of perjury. When you sign the form, you are stating that the information you have provided is true and correct. Top of second page, box on left side: Print the names of Petitioner/Plaintiff, Respondent/Defendant, and Other Parent in this box. Use the same names listed on the front page. Top of second page, box on riqht side: Print your case number in this box. Use the same number as the one on the front page. Instructions for how to complete the Proof of Service section of the Request form are in the Information Sheet for Service of Process (form FL-611). The person who serves the request and its attachments must fill out this section of the form. You cannot serve your own request. Page 3 of 3 FL-676 [Rev. January 1, 2003] REQUEST FOR JUDICIAL DETERMINATION OF SUPPORT ARREARAGES (Governmental) 2003 © American LegalNet, Inc.