FL-650 GOVERNMENTAL AGENCY (under Family Code, §§ 17400, 17406): FOR COURT USE ONLY TELEPHONE NO.: FAX NO.: SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT: STATEMENT FOR REGISTRATION OF CALIFORNIA SUPPORT ORDER Support Order Order for Earnings Assignment CASE NUMBER: The local child support agency's statement to register is as follows: 1. The Obligor (the parent ordered to pay support) is a California support order a California order for earnings assignment Petitioner/Plaintiff Other parent Respondent/Defendant 2. An endorsed filed copy of the most recent support order or earnings assignment (or a copy) is attached. 3. a. b c. An affidavit or declaration of Obligor's payment history is attached. A Declaration of Payment History (form FL-420) is attached. The arrearage balance is unknown. 4. The local child support agency's post office address is (specify): 5. Obligor's last known place of residence or mailing address, or address in the records of the California Department of Motor Vehicles, is (specify): 6. States and counties in which the original order for support or order for earnings assignment, and any modifications, are registered (specify): None, or unknown. NOTICE TO OBLIGOR 1. You have 20 days after the date of mailing of this Statement for Registration of California Support Order to petition the court to cancel (vacate) this registration or for other relief. (Family Code, § 5603.) (See the accompanying document to determine the date of mailing.) 2. The local child support agency may seek a health insurance coverage assignment enrolling the children in an appropriate health insurance plan under Family Code section 3761. Page 1 of 1 Form Adopted for Mandatory Use Judicial Council of California FL-650 [Rev. January 1, 2003] STATEMENT FOR REGISTRATION OF CALIFORNIA SUPPORT ORDER (Governmental) Family Code, § 5601 www.courtinfo.ca.gov. 2002 © American LegalNet, Inc.