ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name) FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF IMPERIAL 939 W. MAIN STREET EL CENTRO, CA 92243 PETITIONER: RESPONDENT: ATTACHED DECLARATION IN SUPPORT OF CHILD SUPPORT MODIFICATION CASE NUMBER: I request a modification of child support based upon the following change of circumstance since the last order for child support was entered: 1. Job loss and current unemployment: I lost my job on ___________. I was laid off terminated other:________________________________. I have been looking for work since I lost my job. A list of my job contacts is attached or will be provided at the hearing. I am receiving unemployment benefits and ask that the court base my child support on my unemployment benefits. I am not eligible for unemployment benefits and I ask that the court reduce my child support to zero until I find employment. Change of employment and decrease in earnings: a. I am no longer working for the same employer as I was when the last order was made. I have not worked there since ____________. I am not working there because __________________________. I currently work at _______________________________________________. My occupation is _________________. I earn $____________ per hour and usually work __________ hours per week. My average gross monthly income is $___________________. This is a decrease in my gross monthly earnings of $___________________ from the time of the last order. b. I tried but could not find work at my previous rate of pay. I am still employed at the same place I was when the order was made, but my earnings have decreased. I now earn $_____________ per hour and usually work _______ hours per week. This is a decrease in my gross monthly earnings of $___________. My earnings decreased because __________________________________________________________. Disability and decrease in earnings and/or loss of income: I am currently disabled. My disability began on __________________ and my medical/psychological problem is:______________________________________________. I will be disabled until _____________________. I have attached a Verification of Disability from my treating doctor. (Select one) a. I do not receive disability benefits at this time but I have applied for benefits. I expect to receive state government federal government private insurance other: disability benefits from the ______________________ starting on ____________ in the sum of $_________ monthly. Until I start to receive these benefits, I ask that the court reduce my child support to zero. I do not expect to receive disability benefits in the future because: _____________________ b. ________________________________________. I ask the court to reduce my child support to zero. I receive disability benefits from state government federal government private insurance c. other: _________________________________. I receive $ _____________ monthly. From this disability income the sum of $ ______________ is deducted for child support every month. I ask that child I request any derivative benefits support be suspended and/or reduced during the period of my disability. due to my child(ren) from social security as a result of my disability be offset against the child support order, pursuant to Family Code § 4504. I receive SSI/SSP benefits and have received SSI/SSP benefits since _________________. Thus, child d. support should be set at zero for so long as I continue to receive these benefits. 2. 3. FL-23 (Adopted 01/01/13) DECLARATION IN SUPPORT OF CHILD SUPPORT MODIFICATION Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com SHORT TITLE: CASE NUMBER: 4. Change in income or ability to earn of the other parent: Since the last order for child support was made, the other parent: a. has become employed, earning $ ____________ per hour, working _________, hours per week. b. has received an increase in earnings and now earns $_____________________, per month. now has the ability to obtain employment and earn at least $_______________, per month. c. Attached please find possible job openings for which the other parent is qualified to apply. Recent release from incarceration and decrease in earnings and/or current unemployment: I was incarcerated from: ___________ to _________. I am currently unemployed as a result of my incarceration and am actively looking for work. A list of my job contacts is attached or will be provided at the hearing. I have no current income. I ask the court to reduce my child support to zero until I find a job. I am in a recovery program called: _________________________________________________ and have been there since _____________. The program requires____________________________________. I am not allowed to work for the first _____ weeks/months. Thereafter, I can work as follows: _______________________________________. I have attached verification of my enrollment and participation in this program. I ask the court to reduce my child support to zero until I find a job. Change in child custody and/or timeshare with children in this case: a. I now have primary custody substantial increased timeshare with the children in this case. The children are now with me as follows: . b. My child, ____________________________________, is emancipated because of turning 18 and not turning 19 getting married joining the military by judicial decree. I request in high school support for that child be terminated. Financial hardship: Since the last order was made, I have sustained the following financial hardship(s): a. Statutory Hardship: 1. Expenses of natural or adopted children in the home (Family Code §4071(a)(2)). I provide support for the following or adopted minor children who reside in my home: ___________________________________________________________________________. Attached please find their birth certificates. 2. Extraordinary health expenses and uninsured catastrophic losses (Family Code § 4071(a)(1)): ___________________________________________________________________________. b. Low income adjustment: I request the court order a low income adjustment in this case because I net less than $1000 per month, taking into consideration all allowable deductions and hardships. Court discretion: I request the court use its discretion and deviate from the guideline amount because c. application of the guideline formula wo