FL-615 FOR COURT USE ONLY GOVERNMENTAL AGENCY (Under Family Code, §§ 17400, 17406): 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: STIPULATION FOR JUDGMENT SUPPLEMENTAL JUDGMENT REGARDING PARENTAL OBLIGATIONS AND JUDGMENT CASE NUMBER: 1. This matter proceeded as follows: a. By written stipulation without court appearance. b. By court hearing, appearances as follows: (1) Date: Dept.: (2) Petitioner/plaintiff present Judicial officer: Attorney present (name): (3) Respondent/defendant present Attorney present (name): (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 petitioner/plaintiff 2. This order is based on the attached documents (specify): respondent/defendant other parent. 3. The parties agree that: a. The parent ordered to pay support has read and understands the Advisement and Waiver of Rights for Stipulation on page 5 of this form. The parent ordered to pay support gives up these rights and freely agrees that a judgment may be entered in accordance with this stipulation. b. The amount of support payable by the party 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: (1) We have been fully informed of the guideline amount of support; we agree voluntarily to child support in the amount of $ 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) c. Other rebutting factors (specify): The computer printout attached 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 5 Form Adopted for Alternative Mandatory Use Instead of Form FL-692 Judicial Council of California FL-615 [Rev. July 1, 2011] STIPULATION FOR JUDGMENT OR SUPPLEMENTAL JUDGMENT REGARDING PARENTAL OBLIGATIONS AND JUDGMENT (Governmental) Family Code, §§ 17400, 17402,17406 www.courts.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com FL-615 PETITIONER/PLAINTIFF: CASE NUMBER: RESPONDENT/DEFENDANT: OTHER PARENT: 3. d. Petitioner/plaintiff Respondent/defendant Other parent item 3e below. e. The parent ordered to pay support must pay current child support as follows: Name of child Date of birth (1) are the parents of the children named in 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. 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: one-half or % or (specify amount): $ per month of the costs. Payments must be made to the other parent State Disbursement Unit (2) Other (specify): (3) health-care provider. For a total of $ payable on the day of each month beginning (date): The low-income adjustment applies. The low-income adjustment does not apply because (specify reasons): (4) (5) (6) f. Any support ordered will continue until further order of court, unless terminated by operation of law. 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. The parent receiving support must (1) provide and maintain health insurance The parent ordered to pay support 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-615 [Rev. July 1, 2011] STIPULATION FOR JUDGMENT OR SUPPLEMENTAL JUDGMENT REGARDING PARENTAL OBLIGATIONS AND JUDGMENT (Governmental) Page 2 of 5 FL-615 PETITIONER/PLAINTIFF: CASE NUMBER: RESPONDENT/DEFENDANT: OTHER PARENT: 3. g. The parent ordered to pay support must pay child support for the past periods and in the amounts set forth below. Name of child Date of birth Period of support Amount (1) Other (specify): (2) For a total of $ (3) 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. h. If this is a judgment on a Supplemental Complaint, it does not modify or supersede any prior judgment or order for support or arrearages, unless specifically provided. i. j. 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. All payments, unless specified in item 3e(1) above, must be made to the State Disbursement Unit at the address listed below (specify address): k. An earnings assignment order is issued. l. 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. m. If “The parent ordered to pay support” box is checked in item 3f, a health insurance coverage assignment must issue. n. The parents must notify the local child support agency in writing within 10 days of any change in residence or employment. o. 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. p. The following person (the “other parent ”) is added as a party to this action (name): q. Other (specify): FL-615 [Rev. July 1, 2011] STIPULATION FOR JUDGMENT OR SUPPLEMENTAL JUDGMENT REGARDING PARENTAL OBLIGATIONS AND JUDGMENT (Governmental) Page 3 of 5 FL-615 PETITIONER/PLAINTIFF: CASE NUMBER: RESPONDENT/DEFENDANT: OTHER PARENT: Date: (TYPE OR PRINT NAME) (SIGNATURE OF ATTORNEY FOR LOCAL CHILD SUPPORT AGENCY) (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) (TYPE OR PRINT NAME) (SIGNATURE OF OTHER PARENT) Date: Date: Date: Date: Date: Date: (TYPE OR PRINT NAME) (SIGNATURE OF ATTORNEY FOR OTHER PARENT) JUDGMENT 4. THE COURT SO ORDERS. Date: JUDICIAL OFFICER Number of pages attached: FL-615 [Rev. July 1, 2011] SIGNATURE FOLLOWS LAST ATTACHMENT STIPULATION FOR JUDGMENT OR SUPPLEMENTAL JUDGMENT REGARDING PARENTAL OBLIGATIONS AND JUDGMENT (Governmental) Page 4 of 5 FL-615 PETITIONER/PLAINTIFF: CASE NUMBER: RESPONDENT/DEFENDANT: OTHER PARENT: ADVISEMENT AND WAIVER OF RIGHTS FOR STIPULATION 1. RIGHT TO BE REPRESENTED BY A LAWYER. I understand that I have the right to be represented by a lawyer of my choice at my expense. If I cannot afford a lawyer to represent me, I can ask the court to appoint one to represent me free of charge only if I dispute that I am the parent of the children named in this action and only on the issue of parentage. I understand that the attorney for the local child support agency does not represent me. 2. RIGHT TO A TRIAL. I understand that I have a right to have a judicial officer (1) determine if I am the parent of the children named in the stipulation, (2) decide how much child support I must pay, and (3) decide how much I owe for arrearages (unpaid support). 3. RIGHT TO CONFRONT AND CROSS-EXAMINE WITNESSES. I understand that in a trial any allegations made against me must be proved. At the trial I may be present with a lawyer when witnesses testify, and I may ask them questions. I may also present evidence and witnesses. 5. ADMISSION AND WAIVER OF RIGHTS. I understand that by agreeing to the terms of this stipulation, I am admitting that I am the parent of the children named in the stipulation and I am giving up the rights stated above. 6. WHERE THE STIPULATION INCLUDES CHILD SUPPORT. a. I understand that I will have the duty to obey the support order for the children named in the stipulation until the order is changed by the court or ended by law. b. I also understand that the court will order any support payments to be paid directly from my wages or other earnings and sent to the local child support agency if one is assigned to collect the support. c. I have been advised of the amount of guideline child support and how the proposed child support amount was determined. 7. WHERE THE STIPULATION INCLUDES A PROVISION FOR HEALTH INSURANCE. I understand that I must keep health insurance coverage for the minor children if insurance is available or becomes available to me at no or reasonable cost. A health insurance coverage assignment/National Medical Support Notice may be ordered to get health insurance for my children. 8. I agree to the terms of this stipulation freely and voluntarily. 9. I understand that the local child support agency is required by state law to enforce the duty of support. 10. I UNDERSTAND THAT IF I WILLFULLY FAIL TO SUPPORT MY CHILDREN, CRIMINAL PROCEEDINGS MAY BE INITIATED AGAINST ME. 11. COLLECTION OF SUPPORT. I understand that any support I owe may be collected from any of my property. This collection may be made by intercepting money owed to me by the state or federal government (such as tax refunds, unemployment and disability benefits, and lottery winnings), by taking property I own, by placing a lien on my property, or by any other lawful means. 12. IF I AM REPRESENTED BY AN ATTORNEY, MY ATTORNEY HAS READ AND EXPLAINED TO ME THE TERMS OF THE STIPULATION AND THIS ADVISEMENT AND WAIVER OF RIGHTS, AND I UNDERSTAND THESE TERMS. 4. RIGHT TO HAVE PARENTAGE TESTS WHERE THE LAW PERMITS. I understand that, where the law permits, I have the right to have the court order parentage tests. The court will decide on the tests. The court could order that I pay none, some, or all of the costs of the tests. I have read and understand the Advisement and Waiver of Rights for Stipulation; or Attached is a translation of this Advisement and Waiver of Rights for Stipulation in (specify language): I understand the translation. I understand the translation. Date: Date: (TYPE OR PRINT NAME) (TYPE OR PRINT NAME) (PARTY’S SIGNATURE) (PARTY’S SIGNATURE) DECLARATION OF PERSON PROVIDING INTERPRETATION/TRANSLATION: The party/parties indicated below is/are unable to read or understand this Stipulation for Judgment or Supplemental Judgment Regarding Parental Obligations and Judgment because (Insert name): _________________________ 's primary (Insert name): __________________________'s primary language is (specify): 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 for Judgment or Supplemental Judgment Regarding Parental Obligations and Judgment in the party's primary language. The above-named party said he or she understood the terms of this Stipulation for Judgment or Supplemental Judgment Regarding Parental Obligations and Judgment before signing it. Date: Date: (TYPE OR PRINT NAME) (SIGNATURE) FL-615 [Rev. July 1, 2011] (TYPE OR PRINT NAME) (SIGNATURE) STIPULATION FOR JUDGMENT OR SUPPLEMENTAL JUDGMENT REGARDING PARENTAL OBLIGATIONS AND JUDGMENT (Governmental) Page 5 of 5