ATTACHMENT C CASE NAME: CASE NUMBER: CHILD SUPPORT ATTACHMENT THE FACTS ARE: 1. INCOME A. A COMPUTER PRINTOUT OF THE PARTIES’ FINANCIAL CIRCUMSTANCES IS ATTACHED. OR B. The parties’ incomes and deductions are: Gross Monthly Income Mother: 2. on AFDC/TANF Father: Net Monthly Income on AFDC/TANF TIME SHARE: Custody of the children listed below is shared by the parties in the following approximate percentages: Mother: % Father: % 3. HARDSHIPS: Not Applicable Hardships for the following have been allowed in calculating child support and the approximate ending time for the hardship is listed below: 4. NON-GUIDELINE ORDERS: The child support agreed to by the parties is below or above the statewide child support guidelines. The parties have been informed of their rights under the law. Neither party is acting out of duress or coercion and neither party is receiving public assistance and no application for public assistance is pending. The needs of the children will be adequately met. No change of circumstances will be required to modify this order. 5. OTHER FACTORS: THE COURT ORDERS: 1. Child support for minor children of the parties, including child care and health care expenses is fixed as follows: a. Child support shall commence on: . b. Child Support Child’s Name Monthly Amount Payable by (Name) STIPULATION AND ORDER page one of two (PLUS ATTACHMENTS) Payable to (Name) Due on Petitioner Respondent Rev. 01/01/02 FM-1002 2002 © American LegalNet, Inc. ATTACHMENT C CASE NAME: c. CASE NUMBER: Child Care Expenses Not Applicable As additional child support, child care expenses shall be paid as follows: Mother: % Father: % OR Child care expenses shall be paid as additional child support as follows: Child’s Name Monthly Amount Payable by (Name) Payable to (Name) Due on 2. A wage assignment shall issue for the payment of child support. NOTE: THE PAYOR OF CHILD SUPPORT IS RESPONSIBLE FOR THE PAYMENT OF CHILD SUPPORT DIRECTLY TO THE RECEIPIENT OR THE FAMILY SUPPORT TRUSTEE UNTIL ANY WAGE ASSIGNMENT IS IN PLACE. 3. Service of the Wage Assignment is stayed provided the payor is not more than of child support. 4. All child support payments shall be made to the FAMILY SUPPORT TRUSTEE. FAMILY SUPPORT TRUSTEE: The District Attorney FSB number is: . A copy of this order shall be served on the Santa Clara County Family Support Division of the District Attorney’s Office. 2645 Zanker Road, San Jose, CA 95134 5. Not Applicable HEALTH CARE EXPENSES a. Health insurance coverage for the minor children of the parties shall be maintained by both parties, if available at no or reasonable cost through their respective places of employment or self-employment. Both parties are ordered to cooperate in the presentation, collection, and reimbursement of any health care claims. b. The party providing coverage shall assign the right of reimbursement to the other party. Uninsured health care costs for the children will be shared as follows: c. days late in the payment Mother: % Father: % Note: If you have checked c above, you must also attach the Judicial Council Notice of Rights and Responsibilities, Health Care Costs & Reimbursement Procedures to this Order. 6. VISITATION TRAVEL EXPENSES: Not Applicable Travel expenses for visitation shall be paid or provided by: Mother: 7. % Father: % CHANGE OF EMPLOYMENT Each party shall inform the other party in writing within 15 days of any change in employment, including the employer’s name and address, and telephone number. STIPULATION AND ORDER page two of two (PLUS ATTACHMENTS) Petitioner Respondent Rev. 01/01/02 FM-1002 2002 © American LegalNet, Inc.