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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 IMPERIAL 939 W. MAIN STREET EL CENTRO, CA 92243 PETITIONER: RESPONDENT: ATTACHED DECLARATION IN SUPPORT OF CHILD CASE NUMBER: SUPPORT MODIFICATION

I request a modification of child support based upon the following change of circumstance since the last order for child support was entered:

1. Job loss and current unemployment: I lost my job on . I was laid off terminated other:_____________________. I have been looking for work since I lost my job. A list of my job contacts is attached or will be provided at the hearing. I am receiving unemployment benefits and ask that the court base my child support on my unemployment benefits. I am not eligible for unemployment benefits and I ask that the court reduce my child support to zero until I find employment.

2. Change of employment and decrease in earnings: a. I am no longer working for the same employer as I was when the last order was made. I have not worked there since ____________. I am not working there because ___________________. I currently work at _______. My occupation is . I earn $ per hour and usually work __________ hours per week. My average gross monthly income is $_. This is a decrease in my gross monthly earnings of $___ from the time of the last order. b. I tried but could not find work at my previous rate of pay. I am still employed at the same place I was when the order was made, but my earnings have decreased. I now earn $__ per hour and usually work _______ hours per week. This is a decrease in my gross monthly earnings of $____. My earnings decreased because __________________________________________________________.

3. Disability and decrease in earnings and/or loss of income: I am currently disabled. My disability began on __________________ and my medical/psychological problem is:______________________________________________. I will be disabled until ____________. I have attached a Verification of Disability from my treating doctor. (Select one) a. I do not receive disability benefits at this time but I have applied for benefits. I expect to receive disability benefits from the state government federal government private insurance other: ______________________ starting on ____________ in the sum of $ monthly. Until I start to receive these benefits, I ask that the court reduce my child support to zero. b. I do not expect to receive disability benefits in the future because: _____________________ ________________________________________. I ask the court to reduce my child support to zero. c. I receive disability benefits from state government federal government private insurance other: _________________________________. I receive $ _____________ monthly. From this disability income the sum of $ ______________ is deducted for child support every month. I ask that child support be suspended and/or reduced during the period of my disability. I request any derivative benefits due to my child(ren) from social security as a result of my disability be offset against the child support order, pursuant to Family Code § 4504. d. I receive SSI/SSP benefits and have received SSI/SSP benefits since _________________. Thus, child support should be set at zero for so long as I continue to receive these benefits.

FL-23 (Adopted 01/01/13) DECLARATION IN SUPPORT OF CHILD SUPPORT MODIFICATION Page 1 of 2