Case Name (Petitioner's last name vs. Respondent's last name): Case Number 1 2 Attachment 19 to Declaration for Default or Uncontested Dissolution or Legal Separation (Form FL-170) 1. STATUS OF CASE 3 a. The parties were married on __________________ and separated on __________________. 4 5 6 7 8 The Petitioner requests his/her former name be restored to 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Petitioner requests that the custody and visitation ordered on _____________ shall remain in full force and effect. The child(ren) currently live with the Petitioner Respondent. The child(ren) visit do not visit with the other parent. Since separation the current visitation pattern has been as follows: (Example: FATHER IS VISITING ON THE 1ST, 3RD, AND WHEN APPLICABLE THE FIFTH WEEKEND BEGINNING FRIDAY 6PM TO SUNDAY 6PM.) b. This is a marriage of ________ year(s) and _______ month(s). c. Respondent was served with a Summons and Petition on _____________________. d. Respondent has not filed a Response and default has been submitted or entered. e. There is/are ______ minor child(ren) of this marriage. 2. NAME CHANGE (Only if you checked Item 7(1) of the Petition for Dissolution) ________________________________. 3. CHILD PATERNITY (Select if your child was born prior to the date marriage both in the Petition for Dissolution) AND checked Item 3(d), 7(d) or Petitioner requests that the Court find the minor child(ren), listed below and named on the Petition, was/were born to the parties prior to their marriage and request that judgment of parentage be entered herein. Child's Name(s) _________________________________________ _________________________________________ Date of Birth ___________ ___________ 4. CHILD CUSTODY AND VISITATION (Select all that apply) The minor child(ren) of the marriage are: Child's Name(s) _________________________________________ _________________________________________ _________________________________________ Date of Birth ___________ ___________ ___________ _____________________________________________________________________________ _____________________________________________________________________________ Attachment 19 to Declaration for Default or Uncontested Dissolution or Legal Separation (Form FL-170) Local Form FL-019 Rev. 6/2012 Page ___ of ___ American LegalNet, Inc. www.FormsWorkFlow.com Case Name (Petitioner's last name vs. Respondent's last name): Case Number I am proposing that the court make the following orders for custody (Check both boxes for "joint custody): 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Legal custody to: Physical Custody to: Petitioner requested to only one parent.) Petitioner Petitioner Respondent Respondent Respondent to be the primary custodial parent. (Not applicable is Physical Custody I am proposing that the court make the following orders for visitation: Petitioner Petitioner Respondent to have reasonable rights of visitation as the parties can agree. Respondent to have no visitation rights for the following reasons: ___________________________________________________________________________ ___________________________________________________________________________ 5. CHILD SUPPORT (Select one) Petitioner requests that the child support ordered on _____________ shall remain in full force and effect. Petitioner requests that the Court order child support as set forth in the attachment. 6. SPOUSAL SUPPORT (Only if you checked Item 7(f), 7(g) or both in the Petition for Dissolution) Petitioner requests that the Court find that Petitioner has WAIVED spousal support and that Respondent has not requested spousal support. Accordingly, spousal support is denied to both parties and the Courts jurisdiction to award spousal support is terminated. Petitioner requests that the Court find the issue of spousal support as to both parties is RESERVED effective forthwith upon entry of Judgment. Petitioner requests that the Court order permanent spousal support based on the facts set forth in the attached Spousal Support Questionnaire, pursuant to Family Code Section 4320. 7. PROPERTY DIVISION (Only if you checked Item 4, 5(a or b) or 7(h) of the Petition for Dissolution) Petitioner requests that the Court find that there are no community assets and or debts to divide. Petitioner requests that the Court order the community assets and debts to be divided as set forth in the attached COMMUNITY PROPERTY DECLARATION (FL-160). Petitioner requests that the Court confirm the separate property assets and/or debts as set forth in the attached SEPARATE PROPERTYATTACHMENT. 8. OTHER ORDERS (Optional) Petitioner requests that the Court make other orders as set forth on OTHER ORDERS attachment. I declare under penalty of perjury under the laws of the State of California that the above stated facts are true and correct. Dated: ____________________________________________(Sign) __________________________________(Print name), Petitioner Attachment 19 to Declaration for Default or Uncontested Dissolution or Legal Separation (Form FL-170) Local Form FL-019 Rev. 6/2012 Page ___ of ___ American LegalNet, Inc. www.FormsWorkFlow.com Case Name (Petitioner's last name vs. Respondent's last name): Case Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 CHILD SUPPORT (Use this attachment if the Department of Child Support Services is NOT involved in your case AND no prior court order has been entered. SELECT ONLY ONE.) The Petitioner requests that the Court order Petitioner Respondent to pay the sum of $_________________ per month for child support to Petitioner Respondent, payable on the first day of each month commencing __________________. A computer calculation printout is attached as Exhibit A. Petitioner requests that the obligation to pay child support shall continue until further order of the Court, or until the child(ren) marries, dies, is emancipated, or reaches age 18. The duty of support continues as to an unmarried child(ren) who has attained the age of 18 years, if a full-time high school student, and th resides with a parent, until the time the child completes the 12 grade or attained the age of 19 years, whichever first occurs. Petitioner requests that the Court order that child support is RESERVED effective forthwith upon entry of Judgment. The request is being made without coercion or duress and in the best interest of the children involved as their needs will be adequately met. 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