Stanislaus — 1. Status of Case

Source: https://www.stanislaus.courts.ca.gov/system/files/supplemental-dec-no-19-2016.pdf

Case Name (Petitioner’s last name vs. Respondent’s last name): Case Number

1 Attachment 19 to Declaration for Default or Uncontested Dissolution or Legal Separation (Form FL-170) 2 1. STATUS OF CASE 3 a. The parties were married on __________________ and separated on __________________. 4 b. This is a marriage of ________ year(s) and _______ month(s). 5 c. Respondent was served with a Summons and Petition on _____________________. 6 d. Respondent has not filed a Response and default has been submitted or entered.

7 e. There is/are ______ minor child(ren) of this marriage.

8 2. NAME CHANGE (Only if you checked Item 7(1) of the Petition for Dissolution) 9 The Petitioner requests his/her former name be restored to 10 ________________________________.

11 3. CHILD PATERNITY (Select if your child was born prior to the date marriage AND checked Item 3(d), 7(d) or 12 both in the Petition for Dissolution)

Petitioner requests that the Court find the minor child(ren), listed below and named on the13

Petition, was/were born to the parties prior to their marriage and request that judgment of parentage be entered herein.14

15 Child’s Name(s) Date of Birth _________________________________________ ___________ 16 _________________________________________ ___________

17 4. CHILD CUSTODY AND VISITATION (Select all that apply) 18 Petitioner requests that the custody and visitation ordered on _____________ shall remain in 19 full force and effect.

20 The Petitioner requests that the Court order:

21 Petitioner Respondent shall have SOLE LEGAL JOINT LEGAL and Petitioner Respondent shall have SOLE PHYSICAL JOINT PHYSICAL 22 CUSTODY of the minor child(ren), namely:

23 Child’s Name(s) Date of Birth

_________________________________________ 24
______________________________ ___________

25 _________________________________________ ___________

Attachment 19 to Declaration for Default or Uncontested Dissolution or Legal Separation (Form FL-170) Page ___ of ___

Case Name (Petitioner’s last name vs. Respondent’s last name): Case Number

11 Petitioner Respondent be designated primary caretaker. (Not applicable if you requested sole physical custody above) 22 Petitioner Respondent to have reasonable rights of visitation as the parties can agree. 33 Petitioner Respondent to have no visitation rights for the following reasons: 44 ___________________________________________________________________________ 55 ___________________________________________________________________________

66 5. CHILD SUPPORT (Select one)

77 Petitioner requests that the child support ordered on _____________ shall remain in full force and effect. 88

Petitioner requests that the Court order child support as set forth in the attachment.

99

6. SPOUSAL SUPPORT (Only if you checked Item 7(f), 7(g) or both in the Petition for Dissolution)1010

1111 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 1212 both parties and the Courts jurisdiction to award spousal support is terminated.

1313 Petitioner requests that the Court find the issue of spousal support as to both parties is RESERVED effective forthwith upon entry of Judgment. 1414 Petitioner requests that the Court order permanent spousal support based on the facts set 1515 forth in the attached Spousal Support Questionnaire, pursuant to Family Code Section 4320.

1616 7. PROPERTY DIVISION (Only if you checked Item 4, 5(a or b) or 7(h) of the Petition for Dissolution)

1717 Petitioner requests that the Court find that there are no community assets and or debts to divide.1818 Petitioner requests that the Court order the community assets and debts to be divided as set 1919 forth in the attached COMMUNITY PROPERTY DECLARATION (FL-160).

2020 Petitioner requests that the Court confirm the separate property assets and/or debts as set forth in the attached SEPARATE PROPERTYATTACHMENT. 2121 8. OTHER ORDERS (Optional) 2222 Petitioner requests that the Court make other orders as set forth on OTHER ORDERS attachment. 2323 I declare under penalty of perjury under the laws of the State of California that the above stated facts are true and correct.2424 Dated: ____________________________________________(Sign) 2525 __________________________________(Print name), Petitioner

Attachment 19 to Declaration for Default or Uncontested Dissolution or Legal Separation (Form FL-170) Page ___ of ___

Case Name (Petitioner’s last name vs. Respondent’s last name): Case Number

1 CHILD SUPPORT (Use this attachment if the Department of Child Support Services is NOT involved 2 in your case AND no prior court order has been entered. SELECT ONLY ONE.)

3 The Petitioner requests that the Court order Petitioner Respondent to pay the sum of 4 $_________________ per month for child support to Petitioner Respondent, payable on the first day of each month commencing __________________. A computer calculation printout is attached 5 as Exhibit A.

6 The request for NON-GUIDELINE child support is being made without coercion or duress and in the best interest of the children involved as their needs will be adequately met. The right to support has not 7 been assigned to the County pursuant to Section 11477 of the Welfare and Institutions Code and no public assistance application is pending 8

9 Petitioner requests that the obligation to pay child support shall continue until further order of the Court, or 10 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 11 resides with a parent, until the time the child completes the 12 th grade or attained the age of 19 years, whichever first occurs. 12

13 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 14 children involved as their needs will be adequately met. The right to support has not been assigned to the County pursuant to Section 11477 of the Welfare and Institutions Code and no public assistance 15 application is pending. A computer calculation printout is attached as Exhibit A.

16 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 17 an unmarried child(ren) who has attained the age of 18 years, if a full-time high school student, and resides with a parent, until the time the child completes the 12 th grade or attained the age of 19 years, 18 whichever first occurs.

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Attachment 19 to Declaration for Default or Uncontested Dissolution or Legal Separation (Form FL-170) Page ___ of ___

Case Name (Petitioner’s last name vs. Respondent’s last name): Case Number

CHILD SUPPORT

11 (Use this attachment ONLY if the Department of Child Support Services has established a support order)

22 Petitioner requests that the Court find the matter of child support is currently assigned to the County of Stanislaus. This case is currently enforced by the Department of Child Support Services under the 33 jurisdiction of Superior Court case #________________, entitled __________________________________ vs. ________________________, in the 44 amount of $ per month.

55 Petitioner requests that the Court finds that sufficient notice has been given and payment shall be made to the Department of Child Support Services. Only payments made to the Department of Child 66 Support Services shall be considered as payments towards the above obligation. 77 Petitioner requests that Respondent shall apply for, obtain, and maintain health insurance coverage of the 88 minor if it is available at no or reasonable costs, and notify the Department of Child Support Services or the local child support agency within 30 days of obtaining such insurance coverage. A health insurance 99 coverage assignment shall issue as provided by law.

1010 Petitioner requests that Petitioner and Respondent are ordered to notify the Department of Child Support Services of any change of address, employment, or employment status within 10 days of such change. 1111 Petitioner requests that the obligation to pay child support shall continue until further order of the Court, or 1212 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 1313 th resides with a parent, until the time the child completes the 12 grade or attained the age of 19 years, whichever first occurs. 1414

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Attachment 19 to Declaration for Default or Uncontested Dissolution or Legal Separation (Form FL-170) Page ___ of ___

Case Name (Petitioner’s last name vs. Respondent’s last name): Case Number

CHILD SUPPORT

11 (Use this attachment ONLY if you are receiving public assistance and the Department of Child Support Services has not yet established a support order) 22 Petitioner requests that the Court find the matter of child support is currently assigned to the County 33 of Stanislaus. This case is pending enforcement by the Department of Child Support Services. A Superior Court case WILL BE DETERMINED in the monthly amount TO BE DETERMINED. 44 Petitioner requests that the Court finds that sufficient notice has been given and payment shall be made 55 to the Department of Child Support Services. Only payments made to the Department of Child Support Services shall be considered as payments towards the above obligation. 66 Petitioner requests that Respondent shall apply for, obtain, and maintain health insurance coverage of the 77 minor if it is available at no or reasonable costs, and notify the Department of Child Support Services or the local child support agency within 30 days of obtaining such insurance coverage. A health insurance 88 coverage assignment shall issue as provided by law.

99 Petitioner requests that Petitioner and Respondent are ordered to notify the Department of Child Support Services or the local child support agency of any change of address, employment, or employment status 1010 within 10 days of such change.

1111 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 to1212 an unmarried child(ren) who has attained the age of 18 years, if a full-time high school student, and resides with a parent, until the time the child completes the 12 th grade or attained the age of 19 years,1313 whichever first occurs. 1414

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Attachment 19 to Declaration for Default or Uncontested Dissolution or Legal Separation (Form FL-170) Page ___ of ___

Case Name (Petitioner’s last name vs. Respondent’s last name): Case Number

SPOUSAL SUPPORT QUESTIONNAIRE

11 (Complete if requesting a permanent spousal support order)

22 The Petitioner requests spousal support commencing (date) ________________, in the amount TO BE DETERMINED by court based upon the following facts: 33 EARNING CAPACITY/MARITAL STANDARD OF LIVING: 44 Marketable skills:

55 I have the following job skills:

____________________________________________________________________________________ 66

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77 ____________________________________________________________________________________

88 Job market for those skills:

99 I am currently employed with (employer’s name) __________________________________________ 1010 _______________________________________ and have been since (date) __. My position there is as a (position title) ________________________________ earning $ per 1111 hour/week/month.

1212 I am currently unemployed. I am making the following attempts to seek employment: 1313 ____________________________________________________________________________________

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1414 ____________________________________________________________________________________ 1515

I have been unable to find employment that utilizes my marketable job skills for the following reasons:1616 (Describe the possible need for retraining or education to get more marketable skills or employment, the time and expense to get
education/training to develop skills, and if your earning ability was impaired by periods of unemployment during the marriage

1717 devoted to domestic duties.) ____________________________________________________________________________________

1818 ____________________________________________________________________________________

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1919

2020 CONTRIBUTIONS TO SUPPORTING SPOUSE:

2121 During the marriage I contributed to the education, training, career, or license of my spouse or partner as follows: ____________________________________________________________________________________2222 ____________________________________________________________________________________ 2323 ____________________________________________________________________________________

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Attachment 19 to Declaration for Default or Uncontested Dissolution or Legal Separation (Form FL-170) Page ___ of ___

Case Name (Petitioner’s last name vs. Respondent’s last name): Case Number

ABILITY TO PAY/EARNING CAPACITY:

11 The other party has the ability to pay spousal support because: (Describe current employment and earning 22 capacity, all other sources of income other than employment and their current standard of living.) ____________________________________________________________________________________ 33 ____________________________________________________________________________________ 44 ____________________________________________________________________________________

55 NEEDS OF EACH PARTY/MARITAL STANDARD OF LIVING:

66 During the marriage I was able to do the following which I am currently unable to do without an order for spousal support: (Describe whether you were able to buy property, vehicles or other assets; if you took vacations, had club 77 memberships, etc.; and, if you were able to build a savings or incurred debt.)

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88 ____________________________________________________________________________________ 99 ____________________________________________________________________________________

1010 OBLIGATIONS AND ASSETS:

1111 I currently have the following assets and obligations:

____________________________________________________________________________________1212

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1313 ____________________________________________________________________________________

1414 The other party has the following assets and obligations: 1515 ____________________________________________________________________________________

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1616 ____________________________________________________________________________________ 1717

DURATION OF MARRIAGE:

1818 We were married on _________________, and separated on ___________________, which is _______ 1919 year(s) and _______ month(s) of marriage.

2020 GAINFUL EMPLOYMENT/INTERESTS OF CHILDREN: 2121 My ability to work will will not unduly interfere with the interests of the dependent children in my custody because:2222 ____________________________________________________________________________________ 2323 ____________________________________________________________________________________ ____________________________________________________________________________________ 2424

2525

Attachment 19 to Declaration for Default or Uncontested Dissolution or Legal Separation (Form FL-170) Page ___ of ___

Case Name (Petitioner’s last name vs. Respondent’s last name): Case Number

AGE AND HEALTH:

11 I am _________ years old and my health is as follows: 22 ____________________________________________________________________________________ ____________________________________________________________________________________ 33 ____________________________________________________________________________________

44 The other party is ________ years old and his her health is as follows: 55 ____________________________________________________________________________________

66 ____________________________________________________________________________________ ____________________________________________________________________________________ 77

HISTORY OF DOMESTIC VIOLENCE:

88

There is is not a history of domestic violence between myself and the other party which has been

99 documented by the following: (Describe any restraining orders, arrests, convictions and any emotional distress and consequences of such violence against you by the other party.) 1010 ____________________________________________________________________________________ 1111 ____________________________________________________________________________________

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1212

1313 TAX CONSEQUENCES:

I understand that any award of spousal support will be tax deductible to the other party and will be taxable1414

to me.

1515 BALANCE OF HARDSHIPS:

1616 I understand that the court will be considering the status of both parties based upon the information contained herein. 1717 GOAL OF BECOMING SELF-SUPPORTING: 1818 I understand that it is the goal of the State of California that a supported party will be self-supporting within a “reasonable period of time” and except in marriages of long duration (10 years or more, or as1919 determined by the court), a “reasonable period of time” to be self-supporting may be one-half the length of the marriage (calculated from date of marriage to date of separation) or as determined by the court. 2020 JUST AND EQUITABLE: 2121 In considering this request, I ask the court to consider the following additional factors: (Describe any other 2222 factors you would like the court to know in making its order.) ____________________________________________________________________________________

2323 ____________________________________________________________________________________

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Attachment 19 to Declaration for Default or Uncontested Dissolution or Legal Separation (Form FL-170) Page ___ of ___

Case Name (Petitioner’s last name vs. Respondent’s last name): Case Number

11 COMMUNITY ASSETS AND DEBTS 22 Petitioner requests that the Court order the community assets and or debts are divided as follows: 33

Petitioner be awarded the following community assets and or debts as his/her sole and separate 44 property:

55 Description of Asset/Debt Market Value Loan or Debt Net Value - = 66 - = - = 77 - = - = 88 - = 99 - = - = 1010 - = - = 1111 - = - = 1212 - = - = 1313 Total awarded to Petitioner: $

1414

1515 Respondent be awarded the following community assets and or debts as his/her sole and separate 1616 property:

Description of Asset/Debt Market Value Loan or Debt Net Value1717 - = 1818 - = - = 1919 - = - = 2020 - = - = 2121 - = - = 2222 - = - = 2323 - = - =2424 - = 2525 Total awarded to Respondent: $

Attachment 19 to Declaration for Default or Uncontested Dissolution or Legal Separation (Form FL-170) Page ___ of ___

Case Name (Petitioner’s last name vs. Respondent’s last name): Case Number

EQUALIZATION OF PROPERTY DIVISION

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22 Equalizing Amount (Check and complete only if property division was unequal)

33 Petitioner requests that the Court find the division of assets and debts results in

Petitioner Respondent receiving $_______________ more in net assets and debts 44
resulting in an equalization payment due to Petitioner Respondent in the amount of

55 $______________ which is one-half the difference between the total net assets and debts going

to each party. 66

77 Payment Terms (Check and complete if you are NOT waiving an equalizing payment)

88 In order to equalize the division of assets and debts, Petitioner Respondent requests 99 that Petitioner Respondent pay the sum of $_______________, payable as follows:

1010 $__________ per month commencing within thirty (30) days of entry of judgment 1111 until paid in full.

Per the following terms:1212

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1313 _______________________________________________________________________ 1414 _______________________________________________________________________

1515 Waiver of Equalizing Payment (Check box below if you are waiving the right to receive an equalizing payment. Note: you CANNOT waive the Respondent’s right to receive an equalizing payment.) 1616 Petitioner requests that the Court find the division of assets and debts results in Respondent 1717 more in net assets and debts than the other party. Petitioner knowingly, freely and without duress

or undo pressure WAIVES and releases all rights and claims to receive an equalizing payment1818 from the other party at any time.

1919

2020 Equal Division (Check if the division of property was equal) Petitioner acknowledges the division of community assets and debts constitutes an equal 2121 division of property.

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Attachment 19 to Declaration for Default or Uncontested Dissolution or Legal Separation (Form FL-170) Page ___ of ___

Case Name (Petitioner’s last name vs. Respondent’s last name): Case Number

RETIREMENT BENEFITS

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22 WAIVER OF RETIREMENT BENEFITS 33 Petitioner requests that the Court order that all benefits accrued during the marriage, now or in the future

44 by Respondent under the employee benefit plan:

55 ___________________________________________________________________________________, 66 [Name of pension or other employee benefit plan]

based on Respondent’s employment with ________________________________________________,

77 shall be awarded to Respondent as his/her sole and separate property. Petitioner will not assert any 88 claim to these benefits, and WAIVES and releases all claims, rights, and interest in and to these benefits

under the plan, including, but not limited to, survivor benefits and agrees to execute all documents

99 required by the Plan or employer to release said interest. 1010

1111

1212 DIVISION OF RETIREMENT BENEFITS

Petitioner requests that the Court find that based on Petitioner’s Respondent’s employment with1313
______________________________________________________, during the marriage, a community

1414 interest has arisen in the following plan:

1515 ___________________________________________________________________________________, 1616 [Name of pension or other employee benefit plan]

The parties shall cooperate in the preparation of a Qualified Domestic Relations Order (QDRO) or

1717 retirement benefits order for each plan, which proposed order(s) shall set forth the respective community 1818 interests of the parties and govern the disposition of benefits upon qualification by the plan(s) based upon

the time rule. The court shall reserve jurisdiction over the preparation of the order(s), and division of said

1919 retirement benefits. 2020

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Attachment 19 to Declaration for Default or Uncontested Dissolution or Legal Separation (Form FL-170) Page ___ of ___

Case Name (Petitioner’s last name vs. Respondent’s last name): Case Number

SEPARATE PROPERTY

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Petitioner requests that the Court find the following assets and or debts shall be established as 22 Petitioner’s separate property:

33 Description of Asset/Debt Date Why do you believe this is Separate Property? Acquired (Examples: Acquired prior to Marriage, After 44 Separation, Inheritance, Gift or Bequest)

55

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1212

Petitioner requests that the Court find the following assets and or debts shall be established as1313 Respondent’s separate property:

1414 Description of Asset/Debt Date Why do you believe this is Separate Property? Acquired (Examples: Acquired prior to Marriage, After 1515 Separation, Inheritance, Gift or Bequest)

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Attachment 19 to Declaration for Default or Uncontested Dissolution or Legal Separation (Form FL-170) Page ___ of ___

Case Name (Petitioner’s last name vs. Respondent’s last name): Case Number

11 OTHER ORDERS:

22 ______________________________________________________________________

33 ______________________________________________________________________

44 ______________________________________________________________________

55 ______________________________________________________________________

66 ______________________________________________________________________

77 ______________________________________________________________________

88 ______________________________________________________________________

99 ______________________________________________________________________

1010 ______________________________________________________________________

1111 ______________________________________________________________________

1212 ______________________________________________________________________

1313 ______________________________________________________________________

1414 ______________________________________________________________________

1515 ______________________________________________________________________

1616 ______________________________________________________________________

1717 ______________________________________________________________________

1818 ______________________________________________________________________

1919 ______________________________________________________________________

2020 ______________________________________________________________________

2121 ______________________________________________________________________

2222 ______________________________________________________________________

2323 ______________________________________________________________________

2424 ______________________________________________________________________

2525 ______________________________________________________________________

Attachment 19 to Declaration for Default or Uncontested Dissolution or Legal Separation (Form FL-170) Page ___ of ___