FL-397 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number, and address): FOR COURT USE ONLY TELEPHONE NO. (Optional): E­MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: CASE NUMBER: REQUEST FOR INCOME AND BENEFIT INFORMATION FROM EMPLOYER To (employer name): 1. This notice is served on you, under California Family Code section 3664(b), in regard to your employee (name): 2. I previously served a request for an Income and Expense Declaration (form FL-150) after judgment on your employee and: a. There was no response within 35 days or b. The response was incomplete as to wage information. 3. I request that the information sought be sent to me on or before (date): from the date of this request. , which is at least 15 days 4. I request that you, as the employer of the above employee, provide the following information (indicated by checked boxes below). If you wish, you may return a copy of this form with the information filled out or provide the information on a separate form. a. b. Occupation of employee: (1) Presently employed: Yes No (2) If employed, current employment status: Full time Part time (3) If not presently employed: (a) Date of separation: (b) Reasons for separation: Starting date of employment: Gross salary or wages for the previous month (including commissions, bonuses, and overtime): Total salary or wages for the previous 12 months (including commissions, bonuses, and overtime): Federal income tax withheld for the previous month: State income tax withheld for the previous month: Social Security and Medicare Tax ("FICA" and "MEDI") deducted for the previous month: Any other deductions from the paycheck for the previous month (for each deduction state purpose and amount): c. d. e. f. g. h. i. Page 1 of 2 Form Adopted for Mandatory Use Judicial Council of California FL-397 [Rev. January 1, 2003] REQUEST FOR INCOME AND BENEFIT INFORMATION FROM EMPLOYER Family Code, § 3664 www.courtinfo.ca.gov 2002 © American LegalNet, Inc. PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: CASE NUMBER: j. Benefits provided: (1) Vision insurance (2) (3) (4) (5) Life insurance Health insurance Contributions toward retirement plan Not available Not available Not available Not available Not enrolled Not enrolled Not enrolled Not enrolled Enrolled (specify value to employee): Enrolled (specify value to employee): Enrolled (specify value to employee): Enrolled (specify asset value to employee): k. Use of company assets (vehicle, housing, health club facility, etc.) Not available Not enrolled Enrolled (specify value to employee): Attach a copy of the employee's three most recent pay stubs. 5. You are entitled to have me pay the reasonable costs of copying the information in this request. 6. Under Family Code section 3664(f), your compliance with this request is voluntary except upon order of the court or upon agreement of the parties, employers, and employee affected. Date: (TYPE OR PRINT NAME) (SIGNATURE OF REQUESTING PARTY) NOTICE TO EMPLOYEE I have served a copy of the attached Request for Income and Benefit Information From Employer on your employer under Family Code section 3664(b). Under Family Code section 3664(c), you are notified that: 1. The information sought by me is limited to the income and benefits provided to you by your employer. 2. The information may be protected by right of privacy. 3. If you object to the production of this information by the employer to me, you must notify the court, in writing, of this objection prior to the date specified in paragraph 3 of the attached request. 4. If, upon your objection, I do not agree, in writing, to cancel or narrow the scope of my request, you should consult an attorney regarding your right to privacy and how to protect this right. 5. You may have other rights provided by Family Code section 3664 and otherwise. NOTICE TO REQUESTING PARTY Under Family Code section 3664(e), service of this request on the employer and of the copy of the request on the employee must be by certified mail, postage prepaid, return receipt requested, to the last known address of the party to be served, or by personal service. FL-397 [Rev. January 1, 2003] REQUEST FOR INCOME AND BENEFIT INFORMATION FROM EMPLOYER Page 2 of 2 2002 © American LegalNet, Inc.