SDSC D-036 (Rev. 7/12) STIPULATION AND ORDER ON REQUEST FOR ORDER 226 LONG FORM Page 1 of 2 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): TELEPHONE NO.: FAX NO.(Optional): ATTORNEY FOR (Name): FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO CENTRAL DIVISION, CENTRAL COURTHOUSE, 1100 UNION ST., SAN DIEGO, CA 92101 CENTRAL DIVISION, FAMILY COURT, 1555 6TH AVE., SAN DIEGO, CA 92101 CENTRAL DIVISION, MADGE BRADLEY, 1409 4TH AVE. SAN DIEGO, CA 92101 CENTRAL DIVISION, COUNTY COURTHOUSE, 220 W. BROADWAY, SAN DIEGO, CA 92101 EAST COUNTY DIVISION, 250 E. MAIN ST., EL CAJON, CA 92020 NORTH COUNTY DIVISION, 325 S. MELROSE DR., VISTA, CA 92081 SOUTH COUNTY DIVISION, 500 3RD AVE., CHULA VISTA, CA 91910 PETITIONER RESPONDENT STIPULATION AND ORDER ON REQUEST FOR ORDER - LONG FORM CASE NUMBER Hearing Date: a.m. p.m. Department: Petitioner: Present Not present, represented by: Respondent: Present Not present, represented by: Third Party: Present Not present, represented by: THE PARTIES STIPULATE AND AGREE THAT THE FOLLOWING CHECKED ITEMS ARE: Temporary orders pending the trial of this action or further order of the court. Orders of modification. 1. jointly to the petitioner to the respondent. 2. PHYSICAL CUSTODY: Physical custody of the minor child(ren) is awarded to the petitioner respondent. 3. VISITATION: The petitioner respondent is awarded the following visitation rights: (a) Reasonable visitation with the minor child(ren) as mutually agreed upon between the parties. (b) Specific visitation with the minor child(ren): (state specific visitation) See attachment for additional visitation. The child(ren) will be picked up at, and returned to, their residence by the party having visitation. The party with physical custody is required to have the child(ren) ready at the designated time, with appropriate clothing provided. However, if the party with visitation fails to appear within hour(s) of the designated time, visitation rights for that specific visitation period are relinquished. The child(ren) must be fed before being returned and all clothing provided must be returned with the child(ren). Jurisdiction. This court has jurisdiction to make child custody orders in this case under the Uniform Child Custody Jurisdiction and Enforcement Act (part 3 of the Fam. Code, commencing with 247 3400). Notice and opportunity to be heard. The responding party was given notice and an opportunity to be heard, as provided by the laws of the State of California. The proper venue is the County of San Diego, State of California Other . Penalties for violating this order. If you violate this order, you may be subject to civil or criminal penalties, or both. 4. CHILD SUPPORT: (a) Base child support must be paid by petitioner respondent beginning and continuing until further order of the court, or until the child marries, dies, is emancipated, reaches age 19, or reaches age 18 and is not a full-time high school student, whichever occurs first, as follows: Child's Name Date of Birth Monthly Amount Payable to (name) See attachment Due: on the 1st of the month 275 on the 1st and 275 on the 15th of the month other: (b) Child care costs related to employment or reasonably necessary job training must be paid by the petitioner respondent in sum of $ per month or % of the total incurred to be paid as follows: American LegalNet, Inc. www.FormsWorkFlow.com SDSC D-036 (Rev. 7/12) STIPULATION AND ORDER ON REQUEST FOR ORDER 226 LONG FORM Page 2 of 2 (c) This stipulated amount is in compliance with Fam. Code 247 4050 et seq., and 247 4053. This stipulated amount is below guideline. The parties declare all the provisions of Fam. Code 247 4065(a)(1) through (5) to be true. 5. (a) An Income Withholding Order is issued pursuant to Fam. Code 247 5230. (b) Stipulation to waive service of an Incoming Withholding Order is made. 6. Child support payments made pursuant to an Income Withholding Order are to be made payable to the State Disbursement Unit (SDU) and sent to: P.O. Box 989067, West Sacramento, CA 95798. 7. 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. 8. SPOUSAL SUPPORT: (a) The petitioner respondent will pay to the petitioner respondent spousal support of $ per week month commencing , payable on the 1st of the month. 275 on the 1st and 275 on the 15th of the month. other: . (b) Jurisdiction reserved until trial. 9. PAYMENTS: Pursuant to Fam. Code 247247 2023 and 2620, each party will pay installments to the following creditors as they become due: PETITIONER RESPONDENT Amount Creditor Amount Creditor See attachment for additional payment information. 10. MEDICAL AND DENTAL: Petitioner Respondent is ordered to maintain all medical and dental benefits available through employment and/or union affiliation, pay the premiums, and cooperate in the presentation, collection, and reimbursement of any claims under such policy for the minor child(ren) and petitioner respondent. 11. ATTORNEY'S FEES: Petitioner Respondent will directly pay the attorney for petitioner respondent $ contribution toward fees and $ costs (on account) payable in installments of $ on the of each month, until paid in full. 12. The exclusive use of the residence and furnishings located at and of the is awarded to the petitioner respondent. 13. OTHER ORDERS: See attachment for other orders. 14. All other issues are reserved until the time of the next hearing date or trial. 15. This matter is continued to at a.m. p.m. in Department for further hearing on all issues. the following issues only: . 16. Attorney for Petitioner Respondent to prepare formal order. This stipulation covers all matters in dispute in the Request for Order. This order, when signed by the court, is the formal order. No further documents are necessary. Date: Signature of Petitioner Attorney for Petitioner Date: Signature of Respondent Attorney for Respondent IT IS SO ORDERED. Fee waiver considered and no repayment is ordered at this time. Date: Judge/Commissioner of the Superior Court SHORT TITLE CASE NUMBER American LegalNet, Inc. www.FormsWorkFlow.com