FL-684 PETITIONER / PLAINTIFF: RESPONDENT / DEFENDANT: OTHER PARENT: CASE NUMBER: (THIS IS A REQUEST, NOT AN ORDER) I REQUEST THE FOLLOWING ORDERS FOR: Name of child Date of birth Name of child Date of birth 1. 2. PARENTAGE. If not previously established, a judgment that you are the parent of the children named above. CHILD SUPPORT. Monthly child support based on the state guideline. (An Income Withholding for Support (FL-195/OMB No. 0970-0154) will be issued.) a. This is a request for a change to an existing order (1) filed on (date if known): (2) ordering (specify): b. Child support to commence (1) on the date this request was mailed or given to you. (2) effective (specify): c. Other (specify): 3. HEALTH INSURANCE COVERAGE If not previously ordered, an order that you provide health insurance for each child named above and an order that you complete the attached health insurance form and immediately return it to the local child support agency. NOTICE: Your employer or other person providing health insurance will be ordered to enroll the children in an appropriate health insurance plan if you are found to be the parent, and a National Medical Support Notice will be issued. 4. 5. FEES AND COSTS Fees: $ Costs: $ PROPERTY RESTRAINT Petitioner/plaintiff Respondent/defendant Other parent be restrained from transferring, encumbering, hypothecating, concealing, or in any way disposing of the following property (specify): Page 1 of 2 Form Adopted for Mandatory Use Judicial Council of California FL-684 [Rev. January 1, 2010] REQUEST FOR ORDER AND SUPPORTING DECLARATION (Governmental) Family Code §§ 215, 3751, 3761, 3900-3901, 4001-4062, 4007, 4009, 4014, 4050-4076, 4200-4204, 7551,17304, 17400, 17402,17404, 17406,17422 www.courtinfo.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com FL-684 PETITIONER / PLAINTIFF: RESPONDENT / DEFENDANT: OTHER PARENT: CASE NUMBER: 6. OTHER (specify): 7. FACTS IN SUPPORT of this request are: contained in an attached declaration. 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) FL-684 [Rev. January 1, 2010] (SIGNATURE OF PERSON REQUESTING THESE ORDERS) Page 2 of 2 REQUEST FOR ORDER AND SUPPORTING DECLARATION (Governmental)