FL-625 GOVERNMENTAL AGENCY (under Family Code, §§ 17400, 17406): FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS: ATTORNEY FOR (name): FAX NO.: SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT/PARTY: STIPULATION AND ORDER 1. This matter proceeded as follows: a. By written stipulation without court appearance. b. (1) (2) (3) (4) (5) (6) By court hearing, appearances as follows: Date: Dept: Petitioner/plaintiff present Respondent/defendant present Other parent/party present Other (specify): Judicial Officer: Attorney present (name): Attorney present (name): Attorney present (name): CASE NUMBER: Local child support agency (Family Code, §§ 17400, 17406) by (name): c. The parent ordered to pay support is the 2. petitioner/plaintiff respondent/defendant other parent/party. This order is based on the attached documents (specify): 3. The parties agree that a. All orders previously made in this action remain in full force and effect except as specifically modified below. b. The amount of support payable by the parent ordered to pay support as calculated under the guideline is: $ per month. We agree to guideline support. The guideline amount should be rebutted because of the following: We have been fully informed of the guideline amount of support; we agree voluntarily to child support of: (1) per month; the agreement is in the best interest of the children; the needs of the children $ will be met adequately by the agreed amount; the children are not receiving public assistance; no application for public assistance is pending; and application of the guideline would be unjust and inappropriate in this case. We understand that if the order is below the guideline, no change of circumstances need be shown for the court to raise this order to the guideline amount. If the order is above the guideline, a change of circumstances will be required to modify this order. (2) Other rebutting factors (specify): c. The attached computer printout shows the parents' incomes and percentage of time each parent spends with the children. The printout, which shows the calculation of child support payable, will become the court's findings. NOTICE: Any party required to pay child support must pay interest on overdue amounts at the legal rate, which is currently 10 percent per year. Form Adopted for Alternative Mandatory Use Instead of Form FL-692 Judicial Council of California FL-625 [Rev. January 1, 2017] Page 1 of 4 STIPULATION AND ORDER (Governmental) Family Code, §§ 17400, 17402, 17404, 17430 www.courts.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com FL-625 PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT/PARTY: CASE NUMBER: 3. d. The parent ordered to pay support must pay current child support as follows: Name of child Date of birth Monthly support amount (1) Mandatory additional child support. (a) The parent ordered to pay support must pay additional monthly support for reasonable child-care costs, as follows: per month of the costs. one-half or % or (specify amount): $ other parent State Disbursement Unit child-care provider. Payments must be made to the (b) The parent ordered to pay support must pay reasonable uninsured health-care costs for the children, as follows: per month of the costs. one-half or % or (specify amount): $ Payments must be made to the other parent State Disbursement Unit health-care provider. Other (specify): (2) (3) (4) For a total of: $ beginning (date): payable on the: day of each month The low-income adjustment applies. The low-income adjustment does not apply because (specify reasons): (5) Any support ordered will continue until further order of court, unless terminated by operation of law. (6) When a person who has been ordered to pay child support is in jail or prison or is involuntarily institutionalized for any period of more than 90 days in a row, the child support order is temporarily stopped. However, the child support order will not be stopped if the person who owes support has the financial ability to pay that support while in jail, prison, or an institution. It will also not be stopped if the reason the person is in jail, prison, or an institution is because the person didn't pay court ordered child support or committed domestic violence against the supported person or child. The child support order starts again on the first day of the month after the person is released from jail, prison, or an institution. e. The parent ordered to pay support The parent receiving support must (1) provide and maintain health insurance coverage for the children if available at no or reasonable cost and keep the local child support agency informed of the availability of the coverage (the cost is presumed to be reasonable if it does not exceed 5 percent of gross income to add a child); (2) if health insurance is not available, provide coverage when it becomes available; (3) within 20 days of the local child support agency's request, complete and return a health insurance form; (4) provide to the local child support agency all information and forms necessary to obtain health-care services for the children; (5) present any claim to secure payment or reimbursement to the other parent or caretaker who incurs costs for health-care services for the children; and (6) assign any rights to reimbursement to the other parent or caretaker who incurs costs for health-care services for the children. The parent ordered to provide health insurance must seek continuation of coverage for the child after the child attains the age when the child is no longer considered eligible for coverage as a dependent under the insurance contract, if the child is incapable of self-sustaining employment because of a physically or mentally disabling injury, illness, or condition and is chiefly dependent upon the parent providing health insurance for support and maintenance. FL-625 [Rev. January 1, 2017] STIPULATION AND ORDER (Governmental) Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com FL-625 PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT/PARTY: CASE NUMBER: 3. f. (1) (2) (3) (4) The parent ordered to pay support owes support arrears as follows, as of (date): Child support: $ Spousal support: $ Interest is not included and is not waived. on the: day of each month Payable: $ beginning (date): Family support: $ Interest accrues on the entire principal balance owing and not on