Orange — Ex Parte Application for Earnings Assignment Order

Source: https://www.occourts.org/system/files/selfhelp/shc-fl-04.pdf

Sparse pages use OCR; original PDF remains authoritative.

SUPERIOR COURT OF CALIFORNIA Self-Help Services COUNTY OF ORANGE www.occourts.org/self-help

EX-PARTE APPLICATION FOR EARNINGS ASSIGNMENT ORDER

SELF-HELP FORM PACKET

SHC-FL-04 (Rev. 01/01/2025)

Self-Help Services can review your completed forms before you file them with the Court. To request review of your completed forms:

1. Complete the attached forms in black ink.
2. Scan your completed forms and save as a single PDF file.
3. Go to www.occourts.org/self-help (click the button labeled Contact Self-Help Services), attach the PDF, and complete the online request form. Make sure to select FAMILY LAW as the case type on the form.

www.occourts.org/self-help

You will need 4 envelopes* with 1 stamp for each, addressed as follows:

a) To you Ex: Josephine Q. Public 123 Happy Lane, Apt. 4 Sunny, CA 90001 b) To the Obligated Party Ex: Mark C. Public (the person who pays) 456 Spiffy Street, Spc. 7 Warm, CA 90002 c) To the Obligated Ex: Jumbo Corp Party's Employer** Attn: 789 Commerce Lane Business, CA 90003 d) To the "California California State Disbursement Unit State Disbursement PO Box 989067 Unit" West Sacramento, CA 95798-9067 ( only if the order involves child support)

*: Other envelopes may be needed, this list is meant as general information. Please seek legal counsel for specific advice about your individual situation.

**: You will need to contact the employer to determine which department or person needs to receive this notice and how to address the envelope to get it to that department or person.

FL-430 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY

TELEPHONE NO.: FAX NO. (Optional):

E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF Orange STREET ADDRESS: 341 The City Drive MAILING ADDRESS: c1TY AND z1P coDE: Orange, CA 92868 BRANCH NAME: Lamoreaux Justice Center

PETITIONER/PLAINTIFF:

RESPONDENT/DEFENDANT: OTHER PARTY/PARENT:

CASE NUMBER: EX PARTE APPLICATION TO D ISSUE, D MODIFY,OR

D TERMINATE AN EARNINGS ASSIGNMENT ORDER

APPLICANT DECLARES

1. CJ Child support was ordered as follows on (date): a. Child's name b. Date of birth c. Monthly amount d. Payable by (party): e. Payable to (party): f. Total amount unpaid (arrears) is at least: $ as of (date):

2. CJ Spousal or domestic partner support D famil y support was ordered as follows: a. Date of order: b. Payable by D petitioner D respondent D other parent c. Payable to D petitioner D respondent D other (specify): d. Total amount unpaid (arrears) is at least: $ as of (date):

3. D Interest and penalties a. The amount of arrears stated in items 1 f and 2d CJ does D does not include interest at the legal rate. (If interest is not included, it is not waived.) b. The amount of arrears stated in items 1 f and 2d CJ does CJ does not include penalties at the legal rate. (If penalties are not included, they are not waived.)

4. CJ (Complete for support ordered before July 1, 1990, only) Payment of CJ child support D spousal or partner support is overdue in the sum of at least one month's payment. Written notice of my intent to seek an earnings assignment was a. D given at least 15 days before the date of filing this application (1) D by first class mail. (2) D by personal service. (3) D contained in the support order described in item 1 or 2. (4) other(specify): D b. D waived (explain):

5. CJ An earnings assignment order has not been issued f or support ordered after July 1, 1990.

   Page 1 of3

Form Adopted for Mandatory Judicial Council of California Use EX PARTE APPLICATION TO ISSUE, MODIFY, OR Family Code, §§ 3901,www.courls.ca.gov5230, 5240, 5252 FL-430 [Rev. January 1, 2014] TERMINATE AN EARNINGS ASSIGNMENT ORDER

FL-430 PETITIONER/PLAINTIFF: CASE NUMBER: RESPONDENT/DEFENDANT: OTHER PARTY/PARENT:

ISSUANCE OF EARNINGS ASSIGNMENT ORDER 6 . I request an earnings assignment order issue for the following monthly deductions: a. O $ per month current child support. b. O $ per month current spousal or domestic partner support. family support. c. 0 $ per month current child support arrears. d. O $ per month e. 0$ per month spousal or domestic partner support arrears. f. 0 $ per month family support arrears. g. Total deductions per month: $ MODIFICATION OF CHILD SUPPORT EARNINGS ASSIGNMENT ORDER (specify):7. O The existing earnings assignment order for child support should be modified as follows

The modified earnings assignment order is requested because (check all that apply):
a. O One or more of the following children listed in the child support order are emancipated (support is no longer
required by law) as of the following dates (name each emancipated child and date of emancipation):

b. 0 The support arrears in this case are paid in full, including interest.
(specify): c. 0 The earnings assignment order must be conformed to the most recent support order as follows

d. 0 The local child support agency is no longer enforcing the current support obligation in this case but is required to
collect and enforce any arrears owing.

(specify): e. 0 Other

TERMINATION OF CHILD SUPPORT EARNINGS ASSIGNMENT ORDER (check all that apply):8. 0 The earnings assignment order for child support should be terminated because a. Past due support has been paid in full, including any interest due. b. O There is no current support order. c. O The child reached age 18 and completed the 12th grade or(date): d. O The child reached 18 and is no longer a full-time high school student as of (date): e. 0 The child reached age 19. (date): f. 0 The child died on (date): g. 0 The child married on (date): h. O The child went on active duty with the armed forces of the United States on (name each child and give i. O The child received a declaration of emancipation under Family Code section 7122 details):

FL-430 [Rev. January 1, 2014] EX PARTE APPLICATION TO ISSUE, MODIFY, OR Page2 of 3 TERMINATE AN EARNINGS ASSIGNMENT ORDER

FL-430 PETITIONER/PLAINTIFF: CASE NUMBER: RESPONDENT/DEFENDANT: OTHER PARTY/PARENT:

8. (continued) (specify): j . D The previous stay of the earnings assignment was improperly terminated k . D The State Disbursement Unit has been unable to deliver payment for a period of six months due to the failure of the support recipient to notify the State Disbursement Unit of a change in his or her address . I . D Other (specify):

MODIFICATION OF SPOUSAL, DOMESTIC PARTNER, OR FAMILY SUPPORT EARNINGS ASSIGNMENT ORDER 9 . D The existing earnings assignment order for spousal, domestic partner, or family support should be changed as follows (specify):

The modified earnings assignment order is requested because (check all that apply):
a. D The support arrears in this case are paid in full, including interest .
(specify): b. D The earnings assignment order must be conformed to the most recent support order as follows

c . D Other (specify):

TERMINATION OF SPOUSAL, DOMESTIC PARTNER, OR FAMILY SUPPORT EARNINGS ASSIGNMENT ORDER (specify):1 o. D The earnings assignment order for spousal, domestic partner, or family support should be terminated because a. Past due support has been paid in full, including any interest due. b. D There is no current support order . c . D The supported spouse or domestic partner remarried or registered a domestic partnership on (date):

(date): d. D The supported spouse or partner died on
(date): e. D By terms of the current order, spousal, partner, or family support terminated on
(specify): f . D A previous stay of wage assignment was improperly terminated

g . D The D employer D State Disbursement Unit has been unable to deliver payment for a period of six
months due to the failure of the support recipient to notify that employer or the State Disbursement Unit of a
change in his or her address.
(specify): h. D Other

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct . Date:

(TYPE OR PRINT NAME) SIGNATURE

FL-430 [Rev. January 1, 2014] EX PARTE APPLICATION TO ISSUE, MODIFY, OR Page 3 of 3 TERMINATE AN EARNINGS ASSIGNMENT ORDER

FL-195 INCOME WITHHOLDING FOR SUPPORT 0MB 0970-0154 Expiration Date: 08/31/2026 I. Sender Information: (Completed by the Sender) Date: INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) AMENDED IWO □ □ ONE-TIME ORDER/NOTICE FOR LUMP SUM PAYMENT TERMINATION OF IWO □ □ D Child Support Agency (CSA) D Court D Attorney D Private Individual/Entity (Check One) NOTE: This IWO must be regular on its face. Under certain circumstances you must reject this IWO and return it to the sender (see IWO instructions www.acf.hhs.gov/css/resource/income-withholding-for-support-instructions). If you receive this document from someone other than a state or tribal CSA agency or a court, a copy of the underlying support order must be attached. State/Tribe/Territory ___________ Remittance ID (include w/payment) ___________ City/County/Dist/Tribe __________ Order ID ____________________ Private Individual/Entity__________ Case ID ____________________ II. Employer and Case Information: (Completed by the Sender) RE: _________________ Employer/Income Withholder's Name Employee/Obliger's Name {Last, First, Middle)

Employer/Income Withholder's Address Employee/Obliger's Social Security Number

Employee/Obliger's Date of Birth

Custodial Party/Obligee's Name (Last, First, Middle)

Employer/Income Withholder's FEIN __________ Child(ren)'s Name(s) {Last, First, Middle) Child(ren)'s Birth Date(s)

Ill. Order Information: (Completed by the Sender) This document is based on the support order from ___________________ (State/Tribe). You are required by law to deduct these amounts from the employee/obliger's income until further notice. $ ______ Per ______ current child support $ ______ Per ______ past-due child support - Arrears greater than 12 weeks? D Yes D No $ ______ Per ______ current cash medical support $ ______ Per ______ past-due cash medical support $ ______ Per ______ current spousal support $ ______ Per ______ past-due spousal support $ ______ Per ______ other (must specif y) ___________________ for a Total Amount to Withhold of$______ per ________ IV. Amounts to Withhold: (Completed by the Sender) You do not have to vary your pay cycle to be in compliance with the Order Information. If your pay cycle does not match the ordered payment cycle, withhold one of the following amounts: $ _____ per weekly pay period $ _____ per semimonthly pay period (twice a month) $ _____ per biweekly pay period ( every two weeks)$ _____ per monthly pay period $ _____ Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order. Document Tracking ID Page 1 of4

forForm Approved

Judicial Council of California Optional Use INCOME WITHHOLDING FOR SUPPORT 42 U.S.C.Family§ 666(b)(6)(A)(Code§ 5208ii) FL-195 [Rev. January 22, 2024] www.courts.ca.gov

FL-195 Employer/Income Withholder's Name: Employer/Income Withholder's FEIN: Employee/Obligor's Name: SSN: Case ID: Order ID: V. Remittance Information: (Completed by the Sender except for the Return 5 1 7 1 1 12 1120 301 24 20 96.848747 to 5 1 7 1 1 13 1154 300 106 21 90.877708 Sender check box.) If the employee/obligor’s principal place of employment is (State/Tribe), you must begin withholding no later than the first pay period that occurs days after the date of of the order/notice. Send payment within business days of the pay date. If you cannot withhold the full amount of support for any or all orders for this employee/obligor, withhold % of disposable income for all orders. If the employee/obligor’s principal place of employment is not (State/Tribe), obtain withholding limitations, time requirements, the appropriate method to allocate among multiple child support cases/orders, and any allowable employer fees from the jurisdiction of the employee/obligor’s principal place of employment. State-specific withholding limit information is available at www.acf.hhs.gov/css/resource/state-income-withholding- contacts-and-program-requirements. For tribe-specific contacts, payment addresses, and withholding limitations, please contact the tribe at www.acf.hhs.gov/sites/default/files/programs/css/tribal_agency_contacts_printable_pdf.pdf or www.bia.gov/tribalmap/DataDotGovSamples/tld_map.html. You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (CCPA) [15 USC § 1673 (b)]; or 2) the amounts allowed by the law of the state of the employee/obligor’s principal place of employment if the place of employment is in a state; or the tribal law of the employee/obligor’s principal place of employment if the place of employment is under tribal jurisdiction. The CCPA is available at https://www.dol.gov/ agencies/whd/fact-sheets/30-cppa. If the Order Information section does not indicate that the arrears are greater than 12 weeks, then the employer should calculate the CCPA limit using the lower percentage. If there is more than one IWO against this employee/obligor and you are unable to fully honor all |WOs due to federal, state, or tribal withholding limits, you must honor all |WOs to the greatest extent possible, giving priority to current support before payment of any past-due support. If the obligor is a nonemployee, obtain withholding limits from the Supplemental Information section in this IWO. This information is also available at www.acf.hhs.gov/css/resource/state-income-withholding-contacts-and-program- requirements. Remit payment to California State Disbursement Unit (SDU/Tribal Order Payee) at P.O. Box 989067, West Sacramento, CA 95798-9067 (SDU/Tribal Payee Address) Include the Remittance ID with the payment and if necessary this locator code of the SDU/Tribal order payee on the payment. To set up electronic payments or to learn state requirements for checks, contact the State Disbursement Unit (SDU). Contacts and information are found at www.acf.hhs.gov/css/resource/sdu-eft-contacts-and-program-requirements. LJ Return to Sender (Completed by Employer/Income Withholder). Payment must be directed to an SDU in accordance with sections 466(b)(5) and (6) of the Social Security Act or Tribal Payee (see Payments in Section VI). If payment is not directed to an SDU/Tribal Payee or this I|WO is not regular on its face, you must check this box and return the IWO to the sender. If Required by State or Tribal Law: Signature of Judge/Issuing Official: Print Name of Judge/Issuing Official: Title of Judge/Issuing Official: Date of Signature: If the employee/obligor works in a state or for a tribe that is different from the state or tribe that issued this order, a copy of this |IWO must be provided to the employee/obligor. L] If checked, the employer/income withholder must provide a copy of this form to the employee/obligor. FL-196 [Rev. January, 22, 2024 INCOME WITHOLDING FOR SUPPORT (IWO) Page 2 of 4

FL-195 Employer/Income Withholder's Name: Employer/Income Withholder's FEIN: Employee/Obligor's Name: SSN: Case ID: Order ID: VI. Additional Information for Employers/Income Withholders: (Completed by the Sender) Priority: Withholding for support has priority over any other legal process under state law against the same income (section 466(b)(7) of the Social Security Act). If a federal tax levy is in effect, please notify the sender. Payments: You must send child support payments payable by income withholding to the appropriate SDU or to a tribal CSA within 7 business days, or fewer if required by state law, after the date the income would have been paid to the employee/obligor and include the date you withheld the support from his or her income. You may combine withheld amounts from more than one employee/obligor’s income in a single payment as long as you separately identify each employee/obligor’s portion of the payment. Child support payments may not be made through the federal Office of Child Support Services (OCSS) Child Support Portal. Lump Sum Payments: You may be required to notify a state or tribal CSA of upcoming lump sum payments, such as bonuses, commissions, or severance pay, to this employee/obligor. Contact the sender to determine if you are required to report and/or withhold lump sum payments. Employers/income withholders may use the OCSS Child Support Portal (ocsp.acf.hhs.gov/csp/) to provide information about employees who are eligible to receive lump sum payments and to provide contacts, addresses, and other information about their companies. Child support payments may not be made through the federal OCSS Child Support Portal. Liability: If you have any doubts about the validity of this WO, contact the sender. If you fail to withhold income from the employee/obligor's income as the IWO directs, you are liable for both the accumulated amount you should have withheld and any penalties set by state or tribal law/procedure. Anti-Discrimination: You are subject to a fine determined under state or tribal law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against an employee/obligor because of this WO. Supplemental Information: FLAA96 [Rev. January, 22, 2024 INCOME WITHOLDING FOR SUPPORT (IWO) Page 3 of 4

FL-195 Employer/Income Withholder's Name: Employer/Income Withholder's FEIN: Employee/Obligor's Name: SSN: Case ID: Order ID: VII. Notification of Employment Termination or Income Status: (Completed by the Employer/Income Withholder) If this employee/obligor never worked for you or you are no longer withholding income for this employee/obligor, you must! promptly notify the CSA and/or the sender by returning this form to the address listed in the Contact Information section below or by using the OCSS Child Support Portal (ocsp.acf.hhs.gov/csp/). Please report the new employer or income withholder, if known. (] This person has never worked for this employer nor received periodic income. (] This person no longer works for this employer nor receives periodic income. Please provide the following information for the employee/obligor: Termination date: Last known telephone number: Last known address: Final payment date to SDU/Tribal Payee: Final payment amount: New employer's or income withholder's name: New employer's or income withholder's address: VIII. Contact Information: (Completed by the Sender) To Employer/Income Withholder: If you have questions, contact (sender name) by telephone: , by fax: , by email or website: Send termination/income status notice and other correspondence to: (sender address). To Employee/Obligor: If the employee/obligor has questions, contact (sender name) by telephone: , by fax: , by email or website: IMPORTANT: The person completing this form is advised that the information may be shared with the employee/obligor. Encryption Requirements: When communicating this form through electronic transmission, precautions must be taken to ensure the security of the data. Child support agencies are encouraged to use the electronic applications provided by the federal Office of Child Support Services. Other electronic means, such as encrypted attachments to emails, may be used if the encryption method is compliant with Federal Information Processing Standard (FIPS) Publication 140-2 (FIPS PUB 140-2). FL-105 [Rev. January, 22, 2024) INCOME WITHOLDING FOR SUPPORT (IWO) Page 4 of

INCOME WITHHOLDING FOR SUPPORT—Instructions FL-196 The Income Withholding for Support (IWO) is the OMB-approved form used for income withholding in: e Tribal, intrastate, and interstate cases enforced under Title IV-D of the Social Security Act e All child support orders initially issued in the state on or after January 1, 1994 e All child support orders initially issued (or modified) in the state before January 1, 1994 if arrearages occur. This form is the standard format prescribed by the Secretary in accordance with section 466(b)(6)(a)(ii) of the Social Security Act. Except as noted, the following information is required and must be included. Please note: e For the purpose of this WO form and these instructions, “state” is defined as a state or territory. ¢ Dos and don'ts on using this form are found at www.acf.hhs.gov/css/resource/using-the-income- withholding-for-support-form-dos-and-donts. I. Sender Information: (Completed by the sender) Check one box for fields 1a—1d. 1a. Income Withholding Order/Notice for Support (IWO). Check the box if this is an initial |WO. 1b. Amended IWO. Check the box to indicate that this form amends a previous IWO. Any changes to an IWO must be done through an amended IWO. 1c. One-Time Order/Notice For Lump Sum Payment. Check the box when this IWO is to attach a one- time collection of a lump sum payment after receiving notification from an employer/income withholder or other source. When this box is checked, enter the amount in field 14, Lump Sum Payment, in the Amounts to Withhold section. Additional |WOs must be issued to collect subsequent lump sum payments. 1d. Termination of IWO. Check the box to stop income withholding on a child support order. Complete all applicable identifying information to aid the employer/income withholder in terminating the correct IWO. e The OMB expiration date is printed on the IWO form. o However, the IWO sent on a case does not expire on the OMB expiration date—once the IWO has been sent to the employer, then the IWO is in effect until it is terminated by the Issuing Agency. o The Issuing Agency must make any system updates to implement the currently approved I|WO form as soon as possible. In the interim, OMB extended the expiration date of the previously approved form to allow child support agencies to issue an IWO until programing for the currently approved form is complete. te. Date. Date this form is completed and/or signed. 1f. Child Support Agency (CSA), Court, Attorney, Private Individual/Entity (Check one box). Check the appropriate box to indicate which entity is sending the IWO. If this IWO is not completed by a state or tribal CSA, the sender should contact the CSA (see www.acf.hhs.gov/programs/css/resource/state-income-withholding-contacts-and-program-requirements) to determine if the CSA needs a copy of this form to facilitate payment processing. NOTE TO EMPLOYER/INCOME WITHHOLDER: This IWO must be regular on its face. The IWO must be rejected and returned to sender under the following circumstances: e [WO instructs the employer/income withholder to send a payment to an entity other than a state disbursement unit (for example, payable to the custodial party, court, or attorney). Each state is required to operate a state disbursement unit (SDU), which is a centralized facility for collection and disbursement of child support payments. Exception: If this IWO is issued by a court, attorney, or private individual/entity and the initial child support order was entered before January 1,1994 or the order was issued by a tribal CSA, the employer/income withholder must follow the payment instructions on the form. e After processing an IWO, the payment is returned to the income withholder because the order information is not on the child support system and the SDU could not process the payment. The income withholder should return the payment to employee.

Form Approved for Optional Use _ H Family Code § 5208 Judicial Council of California INCOME WITHHOLDING FOR SUPPORT-— Instructions 42 U.S.C. § 666(b)(6)(A)(ii) FL-196 [Rev. January 22, 2024] www.courts.ca,gov

e Form does not contain all information necessary for the employer to comply with the withholding, such as missing Remittance Identifier, invalid case identifier, or missing sender contact information. e Form is altered or contains invalid information, such as “step-down” provisions or other future events that an employer is not required to monitor. e Amount to withhold is not a dollar amount. e Sender has not used the OMB-approved form for the IWO. e Acopy of the underlying order is required and not included. If you receive this document from an attorney or private individual/entity, a copy of the underlying support order containing a provision authorizing income withholding must be attached. 1g. State/Tribe/Territory. Name of state or tribe sending this form. This must be a government entity of the state or a tribal organization authorized by a tribal government to operate a child support program. If you are a tribe submitting this form on behalf of another tribe, complete field 1i. 1h. Remittance ID (include w/payment). Identifier for the SDU/Tribal Payee designated in the Remittance Information section, field 22, that employers/income withholders must include when sending payments for this IWO. The Remittance ID is entered as the case identifier on the electronic funds transfer/ electronic data interchange (EFT/EDI) record. NOTE TO EMPLOYER/INCOME WITHHOLDER: The employer/income withholder must use the Remittance ID when remitting payments so the SDU or tribe can identify and apply the payment correctly. The Remittance ID is entered as the case identifier on the EFT/EDI record. 1i. City/County/Dist./Tribe. Optional field for the name of the city, county, or district sending this form. If entered, this must be a government entity of the state or the name of the tribe authorized by a tribal government to operate a child support program for which this form is being sent. If a tribe is submitting this form on behalf of another tribe, enter the name of that tribe. 1j. Order ID. Optional unique identifier associated with a specific child support obligation. It could be a court case number, docket number, or other identifier designated by the sender. 1k. Private Individual/Entity. Name of the private individual/entity or non-IV-D tribal CSE organization sending this form. 1l. Case ID. Unique identifier assigned to a state or tribal CSA case. In a state IV-D case as defined at 45 Code of Federal Regulations (CFR) 305.1, this is the identifier reported to the Federal Case Registry (FCR). One IWO must be issued for each IV-D case and must use the unique CSA Case ID. For tribes, this would be either the FCR identifier or other applicable identifier. Il. Employer and Case Information: (Completed by the Sender) 2a. Employer/Income Withholder's Name. Name of employer or income withholder. 2b. Employer/Income Withholder's Address. Employer/income withholder's mailing address including street/PO box, city, state, and zip code. (This may differ from the employee/obligor’s work site.) If the employer/income withholder is a federal government agency, the I|WO should be sent to the address listed under Federal Agency Income Withholding Contacts and Program Information at www.acf.hhs.gov/css/resource/federal-agency-iwo-and-medical-contact-information. 2c. Employer/Income Withholder's FEIN. Employer/income withholder's nine-digit Federal Employer Identification Number (if available). 3a. Employee/Obligor’s Name. Employee/obligor’s last name and first name. A middle name is optional. 3b. Employee/Obligor’s Social Security Number. Employee/obligor’s Social Security number or other taxpayer identification number. 3c. Employee/Obligor’s Date of Birth. Employee/obligor’s date of birth is optional. 3d. Custodial Party/Obligee’s Name. Custodial party/obligee’s last name and first name. A middle name is optional. Enter one custodial party/obligee’s name on each IWO form. Multiple custodial parties/ obligees are not to be entered on a single IWO. Issue one IWO per state IV-D case as defined at 45 CFR 305.1. FL-196 [Rev. January, 22, 2024 INCOME WITHHOLDING FOR SUPPORT— Instructions Page 20f7

FL-196 3e. Child(ren)’s Name(s). Child(ren)’s last name(s) and first name(s). A middle name(s) is optional. (Note: If there are more than six children for this WO, list additional children’s names and birth dates in the Supplemental Information section, field 33). Enter the child(ren) associated with the custodial party/obligee and employee/obligor only. Child(ren) of multiple custodial parties/obligees is not to be entered on an IWO. 3f. Child(ren)’s Birth Date(s). Date of birth for each child named. 3g. Blank box. Space for court stamps, bar codes, or other information. Ill. Order Information: (Completed by the Sender) The first field identifies which state or tribe issued the order. The other fields identify the dollar amounts for specific kinds of support (taken directly from the support order) and the total amount to withhold for specific time periods. 4. State/Tribe. Name of the state or tribe that issued the support order. Sa-b. Current Child Support. Dollar amount to be withheld per the time period (for example, week, month) specified in the underlying support order. 6a-b. Past-due Child Support. Dollar amount to be withheld per the time period (for example, week, month) specified in the underlying support order. 6c. Arrears Greater Than 12 Weeks? The appropriate box (Yes/No) must be checked indicating whether arrears are greater than 12 weeks. 7a-b. Current Cash Medical Support. Dollar amount to be withheld per the time period (for example, week, month) specified in the underlying support order. 8a—b. Past-due Cash Medical Support. Dollar amount to be withheld per the time period (for example, week, month) specified in the underlying support order. 9a—b. Current Spousal Support. (Alimony) Dollar amount to be withheld per the time period (for example, week, month) specified in the underlying support order. 10a—b. Past-due Spousal Support. (Alimony) Dollar amount to be withheld per the time period (for example, week, month) specified in the underlying order. 11a—c. Other. Miscellaneous obligations’ dollar amount to be withheld per the time period (for example, week, month) specified in the underlying order. Must specify a description of the obligation (for example, court fees). 12a—b. Total Amount to Withhold. The total amount of the deductions per the corresponding time period. Fields 5a, 6a, 7a, 8a, 9a, 10a, and 11a should total the amount in 12a. NOTE TO EMPLOYER/INCOME WITHHOLDER: An acceptable method of determining the amount to be paid on a weekly or biweekly basis is to multiply the monthly amount due by 12 and divide that result by the number of pay periods in a year. Additional information about this topic is available in Action Transmittal 16-04, Correctly Withholding Child Support from Weekly and Biweekly Pay Cycles (https://www.acf.hhs.gov/css/resource/correctly-withholding-child-support-from-weekly-and-biweekly-pay- cycles) FL-196 [Rev. January, 22, 2024 INCOME WITHHOLDING FOR SUPPORT— Instructions Page 30f7

FL-196 IV. Amount to Withold: (Completed by the Sender) Fields 13a through 13d specify the dollar amount to be withheld for this IWO if the employer/income withholder’s pay cycle does not correspond with field 12b. 13a. Per Weekly Pay Period. Total amount an employer/income withholder should withhold if the employee/obligor is paid weekly. 13b. Per Semimonthly Pay Period. Total amount an employer/income withholder should withhold if the employee/obligor is paid twice a month. 13c. Per Biweekly Pay Period. Total amount an employer/income withholder should withhold if the employee/obligor is paid every two weeks. 13d. Per Monthly Pay Period. Total amount an employer/income withholder should withhold if the employee/obligor is paid once a month. 14. Lump Sum Payment. Dollar amount withheld when the IWO is used to attach a lump sum payment. This field should be used when field 1c is checked. 15. Document Tracking ID. Optional unique identifier for this form assigned by the sender. Please Note: Employer/Income Withholder's Name, FEIN, Employee/Obligor’s Name and SSN, Case ID, and Order ID must appear in the header on page 2 and subsequent pages. V. Remittance Information: (Completed by the Sender except for the Return 5 1 10 1 1 12 1259 962 25 20 96.187164 to 5 1 10 1 1 13 1294 961 105 21 95.655174 Sender check box, field 25. Fields 26-29 are completed only if required by state or tribal law.) Payments are forwarded to the SDU in each state, unless the initial child support order was entered by a state before January 1, 1994, and never modified, accrued arrears, or was enforced by a child support agency or by a tribal CSA. If the order was issued by a tribal CSA, the employer/income withholder must follow the remittance instructions on the form in the Supplemental Information Section. 16. State/Tribe. Name of the state or tribe sending this document. 17. Days. Number of days after the effective date noted in field 18 in which withholding must begin, according to the state or tribal laws/procedures for the employee/obligor’s principal place of employment. 18. Date. Implementation date of this IWO, expressed as date of service, receipt, or mailing. Only one of the three choices is to be entered in the blank line. 19. Business Days. Number of business days within which an employer/income withholder must remit amounts withheld pursuant to the state or tribal laws/procedures of the principal place of employment. 20. Percentage of Disposable Income. The percentage of disposable income that may be withheld from the employee/obligor’s paycheck. It is the sender’s responsibility to determine the percentage an employer/income withholder is required to withhold. Senders must enter a specific percentage and not a range of percentages. FL-196 [Rev. January, 22, 2024] INCOME WITHHOLDING FOR SUPPORT-— Instructions Page 4 of 7

FL-196 NOTE TO EMPLOYER/INCOME WITHHOLDER: The employer/income withholder may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act [15 USC §1673(b)]; or 2) the amounts allowed by the jurisdiction of the employee/obligor’s principal place of employment (i.e., the amounts allowed by state law if the employee/obligor’s principal place of employment is in a state; or the amounts allowed by tribal law if the employee/obligor’s principal place of employment is under tribal jurisdiction). If permitted by the state or tribe, you may deduct a fee for administrative costs. The combined support amount and fee may not exceed the limit on the IWO. State-specific withholding limitations, time requirements, and any allowable employer fees are available at www.acf.hhs.gov/css/resource/state-income-withholding-contacts-and-program-requirements. For tribe-specific contacts, payment addresses, and withholding limitations, please contact the tribe at www.acf.hhs.gov/sites/default/files/programs/css/tribal_agency_contacts_printable_pdf.pdf or https://www.bia.gov/tribalmap/DataDotGovSamples/tld_map.html. Depending on applicable state or tribal law, you may need to consider amounts paid for health care premiums to determine disposable income and apply appropriate withholding limits. A federal government agency may withhold from a variety of incomes and forms of payment, including voluntary separation incentive payments (buy-out payments), incentive pay, and cash awards. Fora more complete list, see 5 CFR 581.103. 21. State/Tribe. Name of the state or tribe sending this document. NOTE TO SENDER: The Sender must designate the correct SDU. In certain cases, the Sender may be required to designate an SDU (field 22), corresponding SDU Address (field 23), and if required Locator Code (field 24) that is different than the Sender's SDU (see OCSS's AT-17-07: Interstate Child Support Payment Processing, https://www.acf.hhs.gov/css/resource/interstate-child-support-payment-processing). The Remittance ID in field 1h must correspond with the SFDU identified in field 22. 22. SDU/Tribal Order Payee. Name of SDU (or payee specified in the underlying tribal support order) to which payments must be sent. 23. SDU/Tribal Payee Address. Address of the SDU (or payee specified in the underlying tribal support order) to which payments must be sent. 24. Locator Code. Optional code of the SDU/Tribal Order payee state where payment is being remitted. Geographic Locator Codes are standard codes for states, counties, cities, and territories issued by the National Institute of Standards and Technology. These were formerly known as Federal Information Processing Standards (FIPS) codes. 25. Return to Sender Checkbox. The employer/income withholder should check this box and return the IWO to the sender if this |WO is not payable to an SDU or Tribal Payee or this WO is not regular on its face as indicated on page 1 of these instructions. 26. Signature of Judge/Issuing Official. Signature of the official authorizing this IWO if required by state or tribal law. 27. Print Name of Judge/Issuing Official. Name of the official authorizing this IWO if required by state or tribal law. 28. Title of Judge/Issuing Official. Title of the official authorizing this |WO if required by state or tribal law. 29. Date of Signature. Date the judge/issuing official signs this IWO if required by state or tribal law. FL-196 [Rev. January, 22, 2024] INCOME WITHHOLDING FOR SUPPORT— Instructions

FL-196 30. Copy of IWO checkbox. Check this box for all intergovernmental IWOs. If checked, the employer/income withholder is required to provide a copy of the IWO to the employee/obligor. VI. Additional Information for Employers/Income Withholders: (Completed by the Sender) The following fields refer to federal, state, or tribal laws that apply to issuing an IWO to an employer/ income withholder. State- or tribal-specific information may be included only in the fields below. 31. Liability. Additional information on the penalty and/or citation of the penalty for an employer/income withholder who fails to comply with the |WO. The state or tribal law/procedures of the employee/obligor’s principal place of employment govern the penalty. 32. Anti-discrimination. Additional information on the penalty and/or citation of the penalty for an employer/income withholder who discharges, refuses to employ, or disciplines an employee/obligor as a result of the IWO. The state or tribal law/procedures of the employee/obligor’s principal place of employment govern the penalty. 33. Supplemental Information. Any state-specific information needed, such as maximum withholding percentage for nonemployees/independent contractors, fees the employer/income withholder may charge the obligor for income withholding, or children’s names and DOBs if there are more than six children on this IWO. Additional information must be consistent with the requirements of the form and the instructions. VII. Notification of Employment Termination or Income Status: (Completed by the Employer/Income Withholder) The employer must complete this section when the employee/obligor’s employment is terminated, income withholding ceases, or if the employee/obligor has never worked for the employer. The employer/income withholder may report new payment sources such as workers’ compensation, if known. 34a—b. Employment/Income Status Checkbox. Check the employment/income status of the employee/obligor. 35. Termination Date. If applicable, date employee/obligor was terminated. 36. Last Known Telephone Number. Last known (home/cell/other) telephone number of the employee/obligor. 37. Last Known Address. Last known home/mailing address of the employee/obligor. 38. Final Payment Date. Date employer sent final payment to SDU/Tribal Payee. 39. Final Payment Amount. Amount of final payment sent to SDU/Tribal Payee. 40. New Employer’s or Income Withholder’s Name. Name of employee’s/obligor’s new employer or income withholder (if known). 41. New Employer’s or Income Withholder’s Address. Address of employee’s/obligor's new employer or income withholder (if known). VIII. Contact Information: (Completed by the Sender) 42. Sender Contact for Employer/Income Withholder. Name of the person that the employer/income withholder can call for information regarding this |WO. If the sender is a victim of family or domestic violence, rather than including direct contact information, enter contact information for someone else who will communicate for you. 43. Sender Telephone Number. Telephone number of the contact person. FL-196 [Rev. January, 22, 2024 INCOME WITHHOLDING FOR SUPPORT-— Instructions Page 60f7

FL-196 44. Sender Fax Number. Optional fax number of the contact person. 45. Sender Email/Website. Optional email or website of the contact person. 46. Sender Address (Termination/Income Status and Correspondence Address). Address to which the employer should return the Employment Termination or Income Status notice. It is also the address that the employer should use to correspond with the issuing entity. 47. Sender Contact for Employee/Obligor. Name of the contact person that the employee/obligor can call for information. 48. Sender Telephone Number. Telephone number of the contact person. 49. Sender Fax Number. Optional fax number of the contact person. 50. Sender Email/Website. Optional email or website of the contact person. Encryption Requirements: You must take precautions to secure data when transmitting the IWO electronically. Child support agencies are encouraged to use the electronic applications provided by the federal Office of Child Support Services. Other electronic means, such as encrypted attachments to emails, may be used if the encryption method is compliant with Federal Information Processing Standard (FIPS) Publication 140-2 (FIPS PUB 140-2). The Paperwork Reduction Act of 1995 (Pub.L. 104-13): Public reporting burden for this mandatory collection of information [42 U.S.C. §§ 66(a)(1), (a)(8) and 666(b)(6)] is estimated to average two to five minutes per response. Information collected for this program is subject to the subject to the federal confidentiality requirements [45 CFR 303.21]. A federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless it displays a currently valid OMB control number. If you have any comments on this collection of information, please contact OCSSFedSystems@acf.hhs.gov FL-196 (Rev. January, 22, 2024] INCOME WITHHOLDING FOR SUPPORT-— Instructions Page 7 of 7

FL-435 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY

TELEPHONE NO.: FAX NO. (Optional) :

E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF Orange

sTREET ADDREss: 341 The City Drive
MAILING ADDRESS:
cITY AND zIP coDE: Orange, CA 92868
BRANCH NAME: Lamoreaux Justice Center

PETITIONER/PLAINTIFF:

RESPONDENT/DEFENDANT:

OTHER PARENT:

EARNINGS ASSIGNMENT ORDER FOR SPOUSAL OR PARTNER SUPPORT CASE NUMBER: D Modification

TO THE PAYOR: This is a court order. You must withhold a portion of the earnings of (specify obligor's name and birthdate):

and pay as directed below. (An explanation of this order is printed on page 2 of this form.)

THE COURT ORDERS

1. You must pay part of the earnings of the employee or other person who has been ordered to pay support, as follows: a. D $ per month current spousal or partner support b. D $ per month spousal or partner support arrearages c. Total deductions per month: $ I I

2. D The payments ordered under item 1 a must be paid to (name, address):

3. D The payments ordered under item 1 b must be paid to (name, address):

4. The payments ordered under item 1 must continue until further written notice from the payee or the court.

5. D This order modifies an existing order. The amount you must withhold may have changed. The existing order continues in effect until this modification is effective.

6. This order affects all earnings that are payable beginning as soon as possible but not later than 10 days after you receive it.

7. You must give the obligor a copy of this order and the blank Request for Hearing Regarding Earnings Assignment (form FL-450) within 10 days.

8. D Other (specify):

9. For the purposes of this order, spousal or partner support arrearages are set at: $ as of (date):

Date: JUDICIAL OFFICER Page 1 of2 Form Adopted for Mandatory Judicial Council of California Use EARNINGS ASSIGNMENT ORDER FOR SPOUSAL CodeFamilyof CivilCode,§§Procedure,299(d),§ 706.031;5208; FL-435 [Rev. January 1, 2005] OR PARTNER SUPPORT 15 u.s.c. §§ 1672-1673 (Family Law) www.courtinfo.ca.gov

INSTRUCTIONS FOR EARNINGS ASSIGNMENT ORDER

1. DEFINITION OF IMPORTANT WORDS IN THE EARNINGS security, (3) state income tax, (4) state disability insurance, ASSIGNMENT ORDER and (5) payments to public employees' retirement systems. a. Earnings: After the obligor's disposable earnings are known, (1) Wages, salary, bonuses, vacation pay, retirement withhold the amount required by the order, but never pay, and commissions paid by an employer; withhold more than 50 percent of the disposable (2) Payments for services of independent contractors; earnings unless the court order specifies a higher (3) Dividends, interest, rents, royalties, and residuals; percentage. Federal law prohibits withholding more than (4) Patent rights and mineral or other natural resource 65 percent of disposable earnings of an employee in any rights; case. (5) Any payments due as a result of written or oral If the obligor has more than one assignment for contracts for services or sales, regardless of title; support, add together the amounts of support due for (6) Payments due for workers' compensation temporary all the assignments. If 50 percent of the obligor's net benefits, or payments from a disability or health disposable earnings will not pay in full all of the insurance policy or program; and assignments for support, prorate it first among all of (7) Any other payments or credits due, regardless of the current support assignments in the same source. proportion that each assignment bears to the total current support owed. Apply any remainder to the b. Earnings assignment order: a court order issued in assignments for arrearage support in the same every court case in which one person is ordered to pay proportion that each assignment bears to the total for the support of another person. This order has priority arrearage owed. If you have any questions, please over any other orders such as garnishments or earnings contact the office or person who sent this form to you. withholding orders. This office or person's name appears in the upper Earnings should not be withheld for any other order left-hand corner of the order. until the amounts necessary to satisfy this order have been withheld in full. However, an Order/Notice to b. If the employee's pay period differs from the period Withhold Income for Child Support for child support or specified in the order, prorate the amount ordered withheld family support has priority over this order for spousal or so that part of it is withheld from each of the obligor's partner support. paychecks. c. Obligor: any person ordered by a court to pay support. c. If the obligor stops working for you, notify the office that The obligor is named before item 1 in the order. sent you this form of that, no later than the date of the next payment, by first-class mail. Give the obligor's last known d. Obligee: the person or governmental agency to whom address and, if known, the name and address of any new the support is to be paid. employer. e. Payor: the person or entity, including an employer, that d. California law prohibits you from firing, refusing to hire, or pays earnings to an obligor. taking any disciplinary action against any employee
2. INFORMATION FOR ALL PAYORS. Withhold money from ordered to pay support through an earnings assignment. the earnings payable to the obligor as soon as possible but Such action can lead to a $500 civil penalty per employee. no later than 10 days after you receive the Earnings Assignment Order for Spousal or Partner Support. Send the withheld money to the payee(s) named in items 2 and 3 of 4. INFORMATION FOR ALL OBLIGORS. You should have received a Request for Hearing Regarding Earnings the order within 10 days of the pay date. You may deduct $1 Assignment (form FL-450) with this Earnings Assignment from the obligor's earnings for each payment you make. Order for Spousal or Partner Support. If not, you may get one When sending the withheld earnings to the payee, s

in 10 days of the pay date. You may deduct $1 Assignment (form FL-450) with this Earnings Assignment from the obligor's earnings for each payment you make. Order for Spousal or Partner Support. If not, you may get one When sending the withheld earnings to the payee, state from either the court clerk or the family law facilitator. If you the date on which the earnings were withheld. You may want the court to stop or modify your earnings assignment, combine amounts withheld for two or more obligors in a you must file (by hand delivery or mail) an original copy of single payment to each payee, and identify what portion of the form with the court clerk within 10 days of the date you that payment is for each obligor. received this order. Keep a copy of the form for your records. You will be liable for any amount you fail to withhold If you think your support order is wrong, you can ask for a and can be cited for contempt of court. modification of the order or, in some cases, you can have the order set aside and have a new order issued. You can talk to3. SPECIAL INSTRUCTIONS FOR PAYORS WHO ARE an attorney or get information from the family law facilitator EMPLOYERS about this. a. State and federal laws limit the amount you can withhold and pay as directed by this order. This limitation 5. SPECIAL INFORMATION FOR THE OBLIGORWHO IS AN applies only to earnings defined above in item 1a(1) and EMPLOYEE. State law requires you to notify the payees are usually half the obligor's disposable earnings. named in items 2 and 3 of the order if you change your employment. You must provide the name and address of Disposable earnings are different from gross pay your new employer. or take-home pay. Disposable earnings are earnings left after subtracting the money that state or federal law requires an employer to withhold. Generally these required deductions are (1) federal income tax, (2) social

FL-435 [Rev. January 1, 2005] EARNINGS ASSIGNMENT ORDER FOR SPOUSAL Page 2 of 2 OR PARTNER SUPPORT (Family Law)

FL-420 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state Bar number, and address) or FOR COURT USE ONLY GOVERNMENTAL AGENCY (under Family Code, §§ 17400, 17406):

TELEPHONE NO.: FAX NO. (Optional):

E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF Orange srnEET ADDREss: 341 The City Drive MAILING ADDRESS: cITY AND zIP coDE: Orange, CA 92868 BRANCH NAME: Lamoreaux Justice Center PETITIONER/PLAINTIFF:

RESPONDENT/DEFENDANT:

OTHER PARENT: CASE NUMBER: DECLARATION OF PAYMENT HISTORY

1. Declaration of (name):
2. Based on my records or my recollection, I declare that the information on the attached pages showing the amounts ordered and the amounts paid are true and correct for the following obligations (check all that apply): a. D Child support d. D Medical support g. D Other (specify): b. D Spousal support e. D Unreimbursed medical expenses Unreimbursed child care expenses Family support f. c. D D
3. Number of pages attached_· ___

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Date: ► (TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT)

SUPPORT ARREARAGE SUMMARY

This summary is for arrearage for the periods specified in the attached pages. Interest is calculated through (specify date):

Principal: Interest Cog_tional): Total Arrearage:

CHILD SUPPORT: $ $ $ SPOUSAL SUPPORT: $ $ $ FAMILY SUPPORT: $ $ $ MEDICAL SUPPORT: $ $ $ UN REIMBURSED MEDICAL EXPENSES: $ $ $ UN REIMBURSED CHILD CARE EXPENSES: $ $ $ OTHER (specify): $ $ $ NOTICE: Interest that is not calculated is not waived

Date: Submitted by: ► (TYPE OR PRINT NAME) (SIGNATURE) Details of the arrearage statement, consisting of (specify number) pages, are attached. Page 1 of 1 Fo d se Family Code, §§ 5230.5, U:d:VW1PX: uYZ1 f ! ; ; DECLARATION OF PAYMENT HISTORY 17524(a), 17526(c) FL-420 [Rev. January 1, 2003] (Family Law-Governmental-Uniform Parentage Act) www.courtinfo.ca.gov

FL-421 PETITIONER/PLAINTIFF: CASE NUMBER:

RESPONDENT/DEFENDANT:

OTHER PARENT:

PAYMENT HISTORY FOR (check one): D Child D Spousal D Family D Medical D Unreimbursed child care D Unreimbursed medical D Other (specify):

Year Year Year

AMOUNT AMOUNT AMOUNT AMOUNT AMOUNT AMOUNT
ORDERED PAID ORDERED PAID ORDERED PAID

January

February

March

April

May

June

July

August

September

October

November

December
TOTAL

Year Year Year

AMOUNT AMOUNT AMOUNT AMOUNT AMOUNT AMOUNT
ORDERED PAID ORDERED PAID ORDERED PAID

January

February

March

April

May

June

July

August

September

October

November

December
TOTAL

Page1of __

Form Approved for Optional Judicial Council of Cal9ornia Use PAYMENT HISTORY ATTACHMENT Family17524Code,(a),§§17526(c)5230.5, FL-421 [Rev. July 1, 2003] (Family Law-Governmental-Uniform Parentage Act) www.courtinfo.ca.gov

INSTRUCTIONS FOR COMPLETING PAYMENT RECORD You must complete a separate Payment History Attachment form for each type of support paid. Enter the year, list the amount ordered, and the amount paid for each month during that year. If the amounts repeat in a column, you can use an arrow as shown in the example below. Add the amounts in each column to get the yearly totals. Enter the totals at the bottom. Attach additional sheets and supporting documents (bills, receipts, and other proof of expense) as necessary.

WChild W Spousal Year 2000 Year 2001

AMOUNT AMOUNT AMOUNT AMOUNT AMOUNT AMOUNT
ORDERED PAID ORDERED PAID ORDERED PAID

January 100 0 100 100 January 100 0 February 0 February I March / ,I/ March "-1/ "' 100 100 April 100 April May 100 0 May 100 June 100 June 100 I July 0 July 0

August v100 August I

September 100 September V V October 100 0 October 100

I September 100 September V V October 100 0 October 100

November November / V I "- V I ' I "- ",/ December December ,v V "' IV 1,200 600 TOTAL 1,200 600 1,200 400 TOTAL

UNREIMBURSED CHILD CARE. MEDICAL, OR OTHER EXPENSES: You must complete a separate Payment History Attachment form for each type of unreimbursed expense. If you have more than one bill, receipt, and other proof of expense per month use an additional declaration page (form MC-031) or separate page. 1.) Itemize each expense; 2.) attach proof of bill or payment; 3.) mark each bill or payment with an Exhibit# __; 4.) group the bills, receipts, and other proof of expense in chronological order for each month; and 5.) enter the total bills, receipts, and other proof of expense for each month. If your court order did not state a specific due date for reimbursement, then include that amount in the month that the expense was incurred. W Unreimbursed child care expenses W Unreimbursed medical expenses Year -2001- Year -2001- Form MC-031 Petitioner/Plaintiff AMOUNT AMOUNT AMOUNT AMOUNT CASE NUMBER I ORDERED PAID ORDERED PAID DefendanVRespondent January 50% ($200) 0 January 50% ($200) 0 I request reimbursement for 50% of these expenses, which February 50% ($200) 100 February are supported by copies of bills, receipts, and other proof of expense. March 50% ($200) 0 March 50% ($200) 0 01/04/01 Dr. Adams $45.00 Exhibit A April 50% ($200) 50 April 50% ($75) 0 01/08/01 Dr. Lee, D.D.S. $155.00 Exhibit B May May 02/15/01 AB X-ray Inc. $200.00 ExhibitC June June 04/26/01 Kids Therapy $75.00 Exhibit D July July Child care expenses: 01/02 ABC School 50%($200 August August 02/02 ABC School 50%($200) u - Exhibit E 03/02 ABC School 50%($200) September September 04/02 ABC School 50%($200) October October I declare under penalty of perjury under the laws of the State November November ofCalifornia that the foregoing is true and correct. ........................... December December (TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT) ATTACHED DECLARATION $400 150 $237.50 0 TOTAL TOTAL FormMC-031

PAYMENT HISTORY ATTACHMENTFL-421 [Rev. July 1, 2003] (Family Law-Governmental-Uniform Parentage Act)

MC-031 PLAINTIFF/PETITIONER: CASE NUMBER:

DEFENDANT/RESPONDENT:

DECLARATION

(This form must be attached to another form or court paper before it can be filed in court.)

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Date:

(TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT)
D Attorney for D Plaintiff D Petitioner D Defendant
D Respondent D Other (Specify):

Form Approved for Optional Use Judicial Council of California ATTACHED DECLARATION MC-031 IRev. July 1, 2005] Page 1 of 1

FL-335 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY

TELEPHONE NO.: FAX NO. (Optional).·

E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF Orange STREET ADDRESS: 341 The City Drive MAILING ADDRESS:

CITY AND ZIP CODE: Orange, CA 02868
BRANCH NAME: Lamoreaux Justice Center
CASE NUMBER:
PETITIONER/PLAINTIFF:

RESPONDENT/DEFENDANT: (If applicable, provide): OTHER PARENT/PARTY: HEARING DATE: HEARING TIME: PROOF OF SERVICE BY MAIL DEPT.:

NOTICE: To serve temporary restraining orders you must use personal service (see form FL-330).

1. I am at least 18 years of age, not a party to this action, and I am a resident of or employed in the county where the mailing took

   place.

2. My residence or business address is:

3. I served a copy of the following documents (specify):

   by enclosing them in an envelope AND a. D depositing the sealed envelope with the United States Postal Service with the postage fully prepaid. b. D placing the envelope for collection and mailing on the date and at the place shown in item 4 following our ordinary business practices. I am readily familiar with this business's practice for collecting and processing correspondence for mailing. On the same day that correspondence is placed for collection and mailing, it is deposited in the ordinary course of business with the United States Postal Service in a sealed envelope with postage fully prepaid.

4. The envelope was addressed and mailed as follows: a. Name of person served: b. Address:

   c. Date mailed: d. Place of mailing (city and state):

5. D I served a request to modify a child custody, visitation, or child support judgment or permanent order which included an address verification declaration. (Declaration Regarding Address Verification-Postjudgment Request to Modify a Child Custody, Visitation, or Child Support Order (form FL-334) may be used for this purpose.)

6. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Date: ► (TYPE OR PRINT NAME) (SIGNATURE OF PERSON COMPLETING THIS FORM)

Form Approved for Optional Use Code of Civil Procedure,§§ 1013, 1013a Judicial Council of California PROOF OF SERVICE BY MAIL www.courls.ca.gov FL-335 [Rev. January 1, 2012]

FL-335-INFO

INFORMATION SHEET FOR PROOF OF SERVICE BY MAIL

Use these instructions to complete the Proof of Service by Mail (form FL-335).

A person at least 18 years of age or older must serve the documents. There are two ways to serve documents: (1) personal delivery and (2) by mail. See the Proof of Personal Service (form FL-330) if the documents are being personally served. The person who serves the documents must complete a proof of service form for the documents being served. You cannot serve documents if you are a party to the action.

INSTRUCTIONS FOR THE PERSON WHO SERVES THE DOCUMENTS (TYPE OR PRINT IN BLACK INK)

You must complete a proof of service for each package of documents you serve. For example, if you serve the respondent and the other parent, you must complete two proofs of service; one for the respondent and one for the other parent.

Complete the top section of the proof of service forms as follows: First box, left side: In this box print the name, address, and phone number of the person for whom you are serving the documents. Second box, left side: Print the name of the county in which the legal action is filed and the court's address in this box. Use the same address for the court that is on the documents you are serving. Third box, left side: Print the names of the petitioner/plaintiff, respondenUdefendant, and other parent in this box. Use the same names listed on the documents you are serving. First box, top of form, right side: Leave this box blank for the court's use. Second box, right side: Print the case number in this box. This number is also stated on the documents you are serving. Third box, right side: Print the hearing date, time, and department. Use the same information that is on the documents you are serving. You cannot serve a temporary restraining order by mail. You must serve those documents by personal service.

1. You are stating that you are at least 18 years old and that you are not a party to this action. You are also stating that you either live in or are employed in the county where the mailing took place.
2. Print your home or business address.
3. List the name of each document that you mailed (the exact names are listed on the bottoms of the forms). a. Check this box if you put the documents in the regular U.S. mail. b. Check this box if you put the documents in the mail at your place of employment.
4. a. Print the name you put on the envelope containing the documents. b. Print the address you put on the envelope containing the documents. c. Print the date that you put the envelope containing the documents in the mail. d. Print the city and state you were in when you mailed the envelope containing the documents.
5. Check this box if you are serving an address verification form (required for service by mail of a postjudgment request to change a child custody, visitation, or child support order).
6. You are stating under penalty of perjury that the information you have provided is true and correct. Print your name, fill in the date, and sign the form.

If you need additional assistance with this form, contact the family Jaw facilitator in your county.

FL-335-INFO [New January 1, 2012] INFORMATION SHEET FOR PROOF OF SERVICE BY MAIL Code of Civil Procedure,§§www.courts.ca.gov1013, 1013a

FL-334

PARTY WITHOUT ATTORNEY OR ATTORNEY STATE BAR NUMBER: FOR COURT USE ONLY

NAME:

FIRM NAME:

STREET ADDRESS:

CITY: STATE: ZIP CODE:

TELEPHONE NO.: FAX NO.:

EMAIL ADDRESS:

ATTORNEY FOR (name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE STREET ADDRESS: 341 The City Drive South MAILING ADDRESS: same as above CITY AND ZIP CODE: Orange, CA 92868 BRANCH NAME: Lamoreaux Justice Center PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT/PARTY:

DECLARATION REGARDING ADDRESS VERIFICATION— CASE NUMBER:
POSTJUDGMENT REQUEST TO MODIFY A CHILD CUSTODY,
VISITATION, OR CHILD SUPPORT ORDER

1. I am the attorney for petitioner respondent other parent other party in this matter.

2. The request is to modify a judgment or permanent order only for child support and a local child support agency is providing services in the case. Service of the request solely to modify child support will be made on the other party by serving the local child support agency at least 30 days prior to the hearing as provided in Family Code sections 17404(e)(3) and 17406(f).

3. The request is to modify a judgment or permanent orders for child custody, visitation, or child support.
   Note: If you cannot verify the other party's current residence or office address, mail service may not be used. The other party
   must be personally served. Proof of Personal Service (form FL-330) may be used for this purpose.

   a. Before the request was served on the other party by mail, I verified in the previous 30 days that the other party's current
   residence or office address is (specify):

   b. I can confirm that the above address is the other party's current residence or office address because (specify):
   (1) The other party gave me the address listed in item 3a within 30 days before the request was served.
   (2) I have been at the address listed in item 3a within 30 days before the request was served.

   (3) It is the new address that the other party provided on Notice of Change of Address (form MC-040) or other
   pleading and filed with the court on (specify date):

   (4) It is the office address that the other party last gave on a document filed with the court in this case that was
   also served on me as a party in the case.

   (5) I sent the other party a letter by mail to the address in (2) with return receipt requested and the other party signed
   and accepted the letter at that address within the past 30 days.

   (6) I confirmed by another method (specify):
   Continued in Attachment 3b(6).

I declare under penalty of perjury under the laws of the State of California that the foregoing and all attachments are true and correct.

Date:

(TYPE OR PRINT NAME) (SIGNATURE OF PERSON COMPLETING THIS FORM)

Form Approved for of Civil Procedure, §§ 1013, 1013a; Optional Use DECLARATION REGARDING ADDRESS VERIFICATION— CodeJudicial Council of California Family Code, §§ 215, 17404, 17406 FL-334 [Rev. January 1, 2025] POSTJUDGMENT REQUEST TO MODIFY A CHILD CUSTODY, www.courts.ca.gov VISITATION, OR CHILD SUPPORT ORDER

FL-334 PETITIONER/PLAINTIFF: CASE NUMBER: RESPONDENT/DEFENDANT: OTHER PARENT/PARTY:

NOTICE AND SERVICE INFORMATION

If you want to change a judgment or permanent order for child custody, visitation, or child support, a person at least 18 years of age or older must serve the request on the other party by (1) personal delivery or (2) first-class mail or airmail, postage prepaid. Requests to modify a judgment or permanent order for matters other than child custody, visitation, or child support must be served on the other party by personal service.

• If your request is to change a judgment or permanent orders only for child support and a local child support agency is currently providing services, the other party may be served by mail at the office of the local child support agency. Where service is made by mail on the local child support agency, the following apply:

1. The local child support agency must be served not less than 30 days before the hearing date.

2. Attach a copy of this completed form to the proof of service by mail; and

3. File this original form at the court clerk's office.

• If your request is to change a judgment or permanent order for child custody, visitation, or child support and you have verified the other party's current residence or office address, you must:

1. Complete this form to provide the other party's current residence or business address and indicate how you obtained the other party's current residence or office address.

2. Attach a copy of this completed form to the proof of service by mail; and

3. File this original form at the court clerk's office.

• If you cannot verify the other party's current residence or office address, mail service may not be used. The other party must be personally served. Proof of Personal Service (form FL-330) may be used for this purpose.

FL-334 [Rev. January 1, 2025 DECLARATION REGARDING ADDRESS VERIFICATION— Page 2 of 2 POSTJUDGMENT REQUEST TO MODIFY A CHILD CUSTODY, VISITATION, OR CHILD SUPPORT ORDER