FL-625 GOVERNMENTAL AGENCY (Under Family Code, §§ 17400,17406): FOR COURT USE ONLY TELEPHONE NO.: FAX NO. (Optional): E-MAIL ADDRESS (Optional): 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: CASE NUMBER: STIPULATION AND ORDER 1. This matter proceeded as follows: a. b. By written stipulation without court appearance. By court hearing, appearances as follows: Dept.: Judicial officer: (1) Date: Petitioner/plaintiff present Attorney present (name): (2) Attorney present (name): Respondent/defendant present (3) (4) Other parent present Attorney present (name): (5) Local child support agency (Family Code, §§ 17400, 17406) by (name): (6) Other (specify): c. The parent ordered to pay support is the 2. petitioner/plaintiff respondent/defendant other parent. 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. Page 1 of 4 Form Adopted for Alternative Mandatory Use Instead of Form FL-692 Judicial Council of California FL-625 [Rev. July 1, 2011] STIPULATION AND ORDER (Governmental) Family Code, §§ 17400, 17402, 17404, 17430 www.courts.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com FL-625 PETITIONER/PLAINTIFF: CASE NUMBER: RESPONDENT/DEFENDANT: OTHER PARENT: 3. d. The parent ordered to pay support must pay current child support as follows: Date of birth Name of child (1) (2) Monthly support amount Mandatory additional child support (a) The parent ordered to pay support must pay additional monthly support for reasonable child-care costs, as follows: one-half or % or (specify amount): $ per month of the costs. Payments must be made to the other parent State Disbursement Unit child-care provider. (b) The parent ordered to pay support must pay reasonable uninsured health-care costs for the children, as follows: one-half or % or (specify amount): $ per month of the costs. other parent Payments must be made to the State Disbursement Unit health-care provider. Other (specify): (3) For a total of $ (4) beginning (date): The low-income adjustment applies. The low-income adjustment does not apply because (specify reasons): payable on the day of each month (5) Any support ordered will continue until further order of court, unless terminated by operation of law. (6) As provided in Family Code section 4007.5, the obligation of the person ordered to pay support will be temporarily suspended for any period after the first 90 consecutive days in which the person ordered to pay support is incarcerated or involuntarily institutionalized, unless that person has the ability to pay support during that time or has committed certain crimes. Immediately after the person ordered to pay support is released from incarceration or involuntary institutionalization, the support order will restart in the same amount as it was before it was temporarily suspended. 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% 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. July 1, 2011] STIPULATION AND ORDER (Governmental) Page 2 of 4 FL-625 PETITIONER/PLAINTIFF: CASE NUMBER: RESPONDENT/DEFENDANT: OTHER PARENT: 3. f. The parent ordered to pay support owes support arrears as follows, as of (date): (1) (2) (3) (4) Spousal support: $ Family support: $ Child support: $ Interest is not included and is not waived. Payable: $ on the day of each month beginning (date): Interest accrues on the entire principal balance owing and not on each installment as it becomes due. g. No provision of this judgment may operate to limit any right to collect the principal (total amount of unpaid support) or to charge and collect interest and penalties as allowed by law. All payments ordered are subject to modification. h. All payments, unless specified in item 3d(1) above, must be made to the State Disbursement Unit at the address listed below (specify address: i. j. An Income Withholding for Support (form FL-195/OMB No. 0970-0154) will issue. In the event that there is a contract between a party receiving support and a private child support collector, the party ordered to pay support must pay the fee charged by the private child support collector. This fee must not exceed 33 1/3 percent of the total amount of past due support nor may it exceed 50 percent of any fee charged by the private child support collector. The money judgment created by this provision is in favor of the private child support collector and the party receiving support, jointly. k. If “The parent ordered to pay support” box is checked in item 3e, a health insurance coverage assignment must issue. l. The parents must notify the local child support agency in writing within 10 days of any change in residence or employment. m. The Notice of Rights and Responsibilities (Health-Care Costs and Reimbursement Procedures) and Information Sheet on Changing a Child Support Order (form FL-192) is attached. n. The following person (the “other parent”) is added as a party to this action (name): o. Other (specify): Date: (TYPE OR PRINT NAME) (SIGNATURE OF ATTORNEY FOR LOCAL CHILD SUPPORT AGENCY) Date: (TYPE OR PRINT NAME) (SIGNATURE OF PETITIONER) [TYPE OR PRINT NAME) (SIGNATURE OF ATTORNEY FOR PETITIONER) (TYPE OR PRINT NAME) (SIGNATURE OF RESPONDENT) (TYPE OR PRINT NAME) (SIGNATURE OF ATTORNEY FOR RESPONDENT) Date: Date: Date: FL-625 [Rev. July 1, 2011] STIPULATION AND ORDER (Governmental) Page 3 of 4 FL-625 PETITIONER/PLAINTIFF: CASE NUMBER: RESPONDENT/DEFENDANT: OTHER PARENT: Date: (TYPE OR PRINT NAME) (SIGNATURE OF OTHER PARENT) Date: (TYPE OR PRINT NAME) (SIGNATURE OF ATTORNEY FOR OTHER PARENT) ____________________________________________________________________________________________________________ ORDER 4. THE COURT SO ORDERS. Date: JUDICIAL OFFICER Number of pages attached: SIGNATURE FOLLOWS LAST ATTACHMENT DECLARATION OF PERSON PROVIDING INTERPRETATION/TRANSLATION: The party/parties indicated below is/are unable to read or understand this Stipulation and Order because (Insert name) __________________________'s primary language is (specify): (Insert name)__________________________'s primary language is (specify): and he or she and he or she has has has not read the form has not read the form stipulation translated into this language. stipulation translated into this language. I certify under penalty of perjury under the laws of the State of California that I am competent to interpret or translate in the primary language indicated above and that I have, to the best of my ability, read to, interpreted for, or translated for the above-named party the Stipulation and Order in the party's primary language. The above-named party said he or she understood the terms of this Stipulation and Order before signing it. Date: Date: (TYPE OR PRINT NAME) (SIGNATURE) FL-625 [Rev. July 1, 2011] (TYPE OR PRINT NAME) (SIGNATURE) STIPULATION AND ORDER (Governmental) Page 4 of 4