EX-PARTE APPLICATION FOR EARNINGS ASSIGNMENT ORDER

Complete the attached forms in black ink.

Scan your completed forms and save as a single PDF file.

Go to www.occourts.org/self-help (click the blue button labeled

Click Here to 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.

Self-Help Services can review your completed forms before you file them

with the Court. To request review of your completed forms:

EX-PARTE APPLICATION FOR

EARNINGS ASSIGNMENT ORDER

SELF-HELP FORM PACKET

SHC-FL-04 (Rev. 09/01/2021)

www.occourts.org/self-help

SUPERIOR COURT OF CALIFORNIA

COUNTY OF ORANGE

Self-Help Services

www.occourts.org/self-help

Youwillneed4envelopes*with1stampforeach,

addressedasfollows:



Toyou



Ex:



JosephineQ.Public

 123HappyLane,Apt.4

 Sunny,CA90001



TotheObligatedParty



(thepersonwhopays)

Ex:



MarkC.Public



 456SpiffyStreet,Spc.7

 Warm,CA90002



TotheObligated



Party’sEmployer**

Ex:



JumboCorp



 Attn:________

 789CommerceLane

 Business,CA90003



Tothe



“California



StateDisbursement

Unit”

(onlyiftheorderinvolveschild

support)



CaliforniaStateDisbursementUnit



 POBox989067

 WestSacramento,CA95798‐9067



*: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.

Total amount unpaid (arrears) is at least:

Date of order:

Payable by

Payable to

Total amount unpaid (arrears) is at least:

Payment of

Written notice of my intent to seek an earnings assignment was

(1)

(2)

(3)

(4)

(specify):

by first class mail.

by personal service.

contained in the support order described in item 1 or 2.

other

Payable by (party):

Date of birth Monthly amountChild’s name

Payable to (party):

The amount of arrears stated in items 1f and 2d

(If penalties are not included, they are not waived.)

FL-430

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):

TELEPHONE NO.:

FAX NO. (Optional):

ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

BRANCH NAME:

CITY AND ZIP CODE:

STREET ADDRESS:

MAILING ADDRESS:

PETITIONER/PLAINTIFF:

RESPONDENT/DEFENDANT:

OTHER PARTY/PARENT:

FOR COURT USE ONLY

CASE NUMBER:

TERMINATE AN EARNINGS ASSIGNMENT ORDER

EX PARTE APPLICATION TO

MODIFY, OR

ISSUE,

(date):

Spousal or domestic partner support

family support was ordered as follows:

as of (date):

petitioner

other parent

other

respondent

(specify):

Interest and penalties

does

does not include interest at the legal rate. (If interest

does does not include penalties at the legal rate.

(Complete for support ordered before July 1, 1990, only)

petitioner

child support

given at least 15 days before the date of filing this application

An earnings assignment order has not been issued for support ordered after July 1, 1990.

Page 1 of 3

Family Code, §§ 3901, 5230, 5240, 5252

www.courts.ca.gov

EX PARTE APPLICATION TO ISSUE, MODIFY, OR

TERMINATE AN EARNINGS ASSIGNMENT ORDER

Form Adopted for Mandatory Use

Judicial Council of California

FL-430 [Rev. January 1, 2014]

E-MAIL ADDRESS (Optional):

b. c.

d.a.

The amount of arrears stated in items 1f and 2d

is not included, it is not waived.)

APPLICANT DECLARES

is overdue in the sum of at least one month's payment.

spousal or partner support

Child support was ordered as follows on

waived (explain):

Orange

Lamoreaux Justice Center

Orange, CA 92868

341 The City Drive

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.

MODIFICATION OF CHILD SUPPORT EARNINGS ASSIGNMENT ORDER

Past due support has been paid in full, including any interest due.

TERMINATION OF CHILD SUPPORT EARNINGS ASSIGNMENT ORDER

The modified earnings assignment order is requested because (check all that apply):

ISSUANCE OF EARNINGS ASSIGNMENT ORDER

per month current spousal or domestic partner support.

Total deductions per month:

per month current child support.

per month current family support.

per month child support arrears.

per month spousal or domestic partner support arrears.

per month family support arrears.

FL-430

PETITIONER/PLAINTIFF:

RESPONDENT/DEFENDANT:

OTHER PARTY/PARENT:

CASE NUMBER:



The support arrears in this case are paid in full, including interest.

The earnings assignment order must be conformed to the most recent support order as follows (specify):

The earnings assignment order for child support should be terminated because (check all that apply):

There is no current support order.

The child reached age 18 and completed the 12th grade on

The child reached 18 and is no longer a full-time high school student as of

The child died on

The child married on

The child went on active duty with the armed forces of the United States on

details):

The child received a declaration of emancipation under Family Code section 7122 (name each child and give

(date):

EX PARTE APPLICATION TO ISSUE, MODIFY, OR

TERMINATE AN EARNINGS ASSIGNMENT ORDER

FL-430 [Rev. January 1, 2014]

Page 2 of 3

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):

The child reached age 19.



The existing earnings assignment order for child support should be modified as follows (specify):

Other (specify):

I request an earnings assignment order issue for the following monthly deductions:

MODIFICATION OF SPOUSAL, DOMESTIC PARTNER, OR FAMILY SUPPORT EARNINGS ASSIGNMENT ORDER

TERMINATION OF SPOUSAL, DOMESTIC PARTNER, OR FAMILY SUPPORT EARNINGS ASSIGNMENT ORDER

The modified earnings assignment order is requested because (check all that apply):

(continued)

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

(specify):

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.

The previous stay of the earnings assignment was improperly terminated

The existing earnings assignment order for spousal, domestic partner, or family support should be changed as follows

The support arrears in this case are paid in full, including interest.

The earnings assignment order must be conformed to the most recent support order as follows (specify):

Past due support has been paid in full, including any interest due.

10.

The earnings assignment order for spousal, domestic partner, or family support should be terminated because (specify):

There is no current support order.

The supported spouse or domestic partner remarried or registered a domestic partnership on

The supported spouse or partner died on

By terms of the current order, spousal, partner, or family support terminated on

A previous stay of wage assignment was improperly terminated (specify):

(date):

The 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.

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HPSOR\HU

SIGNATURE

(TYPE OR PRINT NAME)

Date:

Other (specify):

EX PARTE APPLICATION TO ISSUE, MODIFY, OR

TERMINATE AN EARNINGS ASSIGNMENT ORDER

FL-430 [Rev. January 1, 2014]

Page 3 of 3

PETITIONER/PLAINTIFF:

RESPONDENT/DEFENDANT:

OTHER PARTY/PARENT:

FL-430

CASE NUMBER:

(specify):

Income Withholding for Support (IWO)

Page 1 of 4

FL-195

INCOME WITHHOLDING FOR SUPPORT

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

Child Support Enforcement (CSE) Agency Court Attorney 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

). If you receive

this document from someone other than a state or tribal CSE 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)

Employer/Income Withholder's Name

Employer/Income Withholder's Address

Employer/Income Withholder's FEIN

RE:

Employee/Obligor's Name (Last, First, Middle)

Employee/Obligor's Social Security Number

Employee/Obligor's Date of Birth

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

Child(ren)'s Name(s) (Last, First, Middle) Child(ren)'s Birth Date(s)

III. 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/obligor's income until further notice.

Per

current child support

Per

past-due child support - Arrears greater than 12 weeks?

$ Per

current cash medical support

Per

past-due cash medical support

$ Per

current spousal support

$ Per

past-due spousal support

$ Per

other (must specify)

for a Total Amount to Withhold of $ per

Yes No

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.

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to provide uniformity and standardization. Public reporting

burden for this collection of information is estimated to average two to five minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing

the collection of information. This is a mandatory collection of information in accordance with 45 CFR 303.100 of the Child Support Enforcement Program. An agency may not conduct or sponsor, and a

person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. If you have

any comments on this collection of information, please contact the Employer Services Team by email at

OMB 0970-0154

Expiration Date: 09/30/2023

Document Tracking ID

www.acf.hhs.gov/css/resource/income-withholding-for-support-instructions

[email protected].

Income Withholding 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:

V. Remittance Information: (Completed by the Sender except for the "Return to 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

. For tribe-specific contacts, payment addresses, and withholding limitations, please

contact the tribe at or

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

. 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 IWOs due to federal,

state, or tribal withholding limits, you must honor all IWOs 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

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

Return to Sender (Completed by Employer/Income Withholder). Payment must be directed to an SDU in

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.

If checked, the employer/income withholder must provide a copy of this form to the employee/obligor.

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 IWO is not regular on its face, you must check this box and return

the IWO to the sender.

www.acf.hhs.gov/css/resource/state-income-withholding-

contacts-and-program-requirements

www.acf.hhs.gov/sites/default/files/programs/csstribal_agency_contacts_printable_pdf.pdf

www.bia.gov/tribalmap/DataDotGovSamples/tld_map.html

www.dol.gov/sites/dolgov/

files/WHD/legacy/files/garn01.pdf

www.acf.hhs.gov/css/resource/state-income-withholding-contacts-and-program-

requirements.

www.acf.hhs.gov/css/resource/sdu-eft-contacts-and-program-requirements.

Income Withholding 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:

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 OCSE Child Support Portal.

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 State Disbursement

Unit or to a tribal CSE agency 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 Enforcement (OCSE) Child Support Portal.

Liability: If you have any doubts about the validity of this IWO, 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 IWO.

Supplemental Information:

Lump Sum Payments: You may be required to notify a state or tribal CSE agency of upcoming lump sum payments to

this employee/obligor such as bonuses, commissions, or severance pay. Contact the sender to determine if you are

required to report and/or withhold lump sum payments. Employers/income withholders may use OCSE’s Child Support

Portal

(

ocsp.acf.hhs.gov/csp/

)

Income Withholding for Support (IWO)

Page 4 of 4

FL-195

Employer/Income Withholder's Name:

Employer/Income Withholder's FEIN:

Employee/Obligor's Name: SSN:

Case ID: Order ID:

Please report the new employer or income

withholder, if known.

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 CSE agency and/or the sender by returning this form to the address listed in the Contact Information

section below or using OCSE’s Child Support Portal

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 Enforcement. 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).

(

ocsp.acf.hhs.gov/csp/

INCOME WITHHOLDING FOR SUPPORT – Instructions

INCOME WITHHOLDING FOR SUPPORT - Instructions

FL-196

The Income Withholding for Support (IWO) is the OMB-approved form used for income withholding in:

Tribal, intrastate, and interstate cases enforced under Title IV-D of the Social Security Act

All child support orders initially issued in the state on or after January 1, 1994, and

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:

For the purpose of this IWO form and these instructions, “state” is defined as a state or territory.

Dos and don’ts on using this form are found at

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 IWO.

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 IWOs 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.

1e. Date. Date this form is completed and/or signed.

1f. Child Support Enforcement (CSE) Agency, 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 CSE agency, the sender should contact the CSE agency (see

to determine if the CSE agency 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:

IWO 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 CSE agency, the employer/income withholder must follow the payment

instructions on the form.

Form does not contain all information necessary for the employer to comply with the withholding.

Form is altered or contains invalid information.

Amount to withhold is not a dollar amount.

Sender has not used the OMB-approved form for the IWO.

A copy 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.

Page 1 of 7

www.acf.hhs.gov/css/resource/using-the-income-

withholding-for-support-form-dos-and-donts.

www.acf.hhs.gov/programs/css/resource/state-income-withholding-contacts-and-program-requirements

)

INCOME WITHHOLDING FOR SUPPORT – Instructions

FL-196

1g. State/Tribe/Territory. Name of state or tribe sending this form. This must be a governmental entity of

the state or a tribal organization authorized by a tribal government to operate a CSE 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 CSE 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.

. Case ID. Unique identifier assigned to a state or tribal CSE 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 CSE Agency Case ID. For

tribes, this would be either the FCR identifier or other applicable identifier.

II. Employer and Case Information: (Completed by the Sender)

2a. Employer/Income Withholder's Name. Name of employer or income withholder.

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 IWO should be sent to the address

listed under Federal Agency Income Withholding Contacts and Program Information at

2b. Employer/Income Withholder's Address. Employer/income withholder's mailing address including

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.

Page 2 of 7

www.acf.hhs.gov/css/resource/federal-agency-iwo-and-medical-contact-information

INCOME WITHHOLDING FOR SUPPORT – Instructions

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 IWO, 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.

III. 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.

5a-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

Page 3 of 7

(

https://www.acf.hhs.gov/css/resource/correctly-withholding-child-support-from-weekly-and-biweekly-pay-

cycles)

INCOME WITHHOLDING FOR SUPPORT – Instructions

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 two and subsequent pages.

V. Remittance Information: (Completed by the Sender except for the "Return to 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 CSE agency. If the order was issued by a tribal CSE agency, 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.

Page 4 of 7

INCOME WITHHOLDING FOR SUPPORT – Instructions

FL-196

NOTE TO EMPLOYER/INCOME WITHHOLDER: The employer/income withholder may not withhold more

than the lesser of: 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

For tribe- specific contacts, payment addresses, and withholding limitations, please contact the tribe at

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. For a

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 OCSE's AT-17-07: 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 payee state where payment is being remitted. Geographic

Locator Codes are standard codes for states, counties, and cities 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 IWO is not payable to an SDU or Tribal Payee or this IWO 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 IWO 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.

Page 5 of 7

www.acf.hhs.gov/css/resource/state-income-withholding-contacts-and-program-requirements

www.acf.hhs.gov/sites/default/files/programs/css/tribal_agency_contacts_printable_pdf.pdf

https://www.bia.gov/tribalmap/DataDotGovSamples/tld_map.html

https://www.acf.hhs.gov/css/resource/interstate-child-support-payment-processing

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 IWO. 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 IWO. 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.

Page 6 of 7

INCOME WITHHOLDING FOR SUPPORT – Instructions

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:

When communicating the Income Withholding for Support (IWO) 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 Enforcement. 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).

Page 7 of 7

FL-435

FOR COURT USE ONLY

PETITIONER/PLAINTIFF:

RESPONDENT/DEFENDANT:

OTHER PARENT:

EARNINGS ASSIGNMENT ORDER FOR SPOUSAL OR PARTNER SUPPORT

CASE NUMBER:

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

You must pay part of the earnings of the employee or other person who has been ordered to pay support, as follows:

per month current spousal or partner support

$ per month spousal or partner support arrearages

Total deductions per month:

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

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

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

5. 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.

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

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.

Other (specify):

as of (date):

For the purposes of this order, spousal or partner support arrearages are set at: $

Date:

JUDICIAL OFFICER

Page 1 of 2

Family Code, §§ 299(d), 5208;Form Adopted for Mandatory Use

Judicial Council of California

FL-435 [Rev. January 1, 2005]

EARNINGS ASSIGNMENT ORDER FOR SPOUSAL

OR PARTNER SUPPORT

(Family Law)

Code of Civil Procedure, § 706.031;

15 U.S.C. §§ 1672–1673

www.courtinfo.ca.gov

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):

TELEPHONE NO.: FAX NO. (Optional):

ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

STREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

E-MAIL ADDRESS (Optional):

Orange

341 The City Drive

Orange, CA 92868

Lamoreaux Justice Center

INSTRUCTIONS FOR EARNINGS ASSIGNMENT ORDER

DEFINITION OF IMPORTANT WORDS IN THE EARNINGS

ASSIGNMENT ORDER

security, (3) state income tax, (4) state disability insurance,

and (5) payments to public employees’ retirement

systems.

Earnings:

Wages, salary, bonuses, vacation pay, retirement

After the obligor’s disposable earnings are known,

withhold the amount required by the order, but never

withhold more than 50 percent of the disposable

earnings unless the court order specifies a higher

percentage. Federal law prohibits withholding more than

65 percent of disposable earnings of an employee in any

pay, and commissions paid by an employer;

Payments for services of independent contractors;

Dividends, interest, rents, royalties, and residuals;

Patent rights and mineral or other natural resource

rights;

case.

Any payments due as a result of written or oral

contracts for services or sales, regardless of title;

If the obligor has more than one assignment for

support, add together the amounts of support due for

all the assignments. If 50 percent of the obligor’s net

disposable earnings will not pay in full all of the

assignments for support, prorate it first among all of

the current support assignments in the same

proportion that each assignment bears to the total

current support owed. Apply any remainder to the

assignments for arrearage support in the same

proportion that each assignment bears to the total

arrearage owed. If you have any questions, please

contact the office or person who sent this form to you.

This office or person's name appears in the upper

left-hand corner of the order.

Payments due for workers’ compensation temporary

benefits, or payments from a disability or health

insurance policy or program; and

Any other payments or credits due, regardless of

source.

Earnings assignment order: a court order issued in

Earnings should not be withheld for any other order

until the amounts necessary to satisfy this order have

been withheld in full. However, an OrderlNotice to

Withhold Income for Child Support for child support or

family support has priority over this order for spousal or

partner support.

If the employee's pay period differs from the period

specified in the order, prorate the amount ordered withheld

so that part of it is withheld from each of the obligor’s

paychecks.

Obligor: any person ordered by a court to pay support.

The obligor is named before item 1 in the order.

If the obligor stops working for you, notify the office that

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

address and, if known, the name and address of any new

employer.

Obligee: the person or governmental agency to whom

the support is to be paid.

Payor: the person or entity, including an employer, that

pays earnings to an obligor.

California law prohibits you from firing, refusing to hire, or

taking any disciplinary action against any employee

ordered to pay support through an earnings assignment.

Such action can lead to a $500 civil penalty per employee.

INFORMATION FOR ALL PAYORS. Withhold money from

the earnings payable to the obligor as soon as possible but

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

the order within 10 days of the pay date. You may deduct $1

from the obligor’s earnings for each payment you make.

INFORMATION FOR ALL OBLIGORS. You should have

received a Request for Hearing Regarding Earnings

Assignment (form FL-450) with this Earnings Assignment

Order for Spousal or Partner Support. If not, you may get one

from either the court clerk or the family law facilitator. If you

want the court to stop or modify your earnings assignment,

you must file (by hand delivery or mail) an original copy of

the form with the court clerk within 10 days of the date you

received this order. Keep a copy of the form for your records.

When sending the withheld earnings to the payee, state

the date on which the earnings were withheld. You may

combine amounts withheld for two or more obligors in a

single payment to each payee, and identify what portion of

that payment is for each obligor.

You will be liable for any amount you fail to withhold

and can be cited for contempt of court.

If you think your support order is wrong, you can ask for a

modification of the order or, in some cases, you can have the

order set aside and have a new order issued. You can talk to

an attorney or get information from the family law facilitator

about this.

SPECIAL INSTRUCTIONS FOR PAYORS WHO ARE

EMPLOYERS

State and federal laws limit the amount you can

withhold and pay as directed by this order. This limitation

applies only to earnings defined above in item 1a(1) and

SPECIAL INFORMATION FOR THE OBLIGOR WHO IS AN

EMPLOYEE. State law requires you to notify the payees

named in items 2 and 3 of the order if you change your

employment. You must provide the name and address of

your new employer.

are usually half the obligor’s disposable earnings.

Disposable earnings are different from gross pay

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

Page 2 of 2

FL-435 [Rev. January 1, 2005]

EARNINGS ASSIGNMENT ORDER FOR SPOUSAL

OR PARTNER SUPPORT

(Family Law)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

every court case in which one person is ordered to pay

for the support of another person. This order has priority

over any other orders such as garnishments or earnings

withholding orders.

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state Bar number, and address) or

GOVERNMENTAL AGENCY (under Family Code, §§ 17400, 17406):

TELEPHONE NO.:

FOR COURT USE ONLY

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

CITY AND ZIP CODE:

BRANCH NAME:

PETITIONER/PLAINTIFF:

RESPONDENT/DEFENDANT:

OTHER PARENT:

CASE NUMBER:

DECLARATION OF PAYMENT HISTORY

Declaration of (name):

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):

Child support

Number of pages attached:

CHILD SUPPORT:

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

NOTICE: Interest that is not calculated is not waived

Date:

(SIGNATURE)

(TYPE OR PRINT NAME)

DECLARATION OF PAYMENT HISTORY

(Family Law—Governmental—Uniform Parentage Act)

Family Code, §§ 5230.5,

17524(a), 17526(c)

Form Adopted for Mandatory Use

Judicial Council of California

FL-420 [Rev. January 1, 2003]

STREET ADDRESS:

MAILING ADDRESS:

FL-420

Page 1 of 1

E–MAIL ADDRESS (Optional):

ATTORNEY FOR (Name):

FAX NO. (Optional):

Details of the arrearage statement, consisting of (specify number) pages, are attached.

Medical support

Spousal support

Family support

Unreimbursed medical expenses

Unreimbursed child care expenses

Date:

(SIGNATURE OF DECLARANT)

(TYPE OR PRINT NAME)

SUPPORT ARREARAGE SUMMARY

This summary is for arrearage for the periods specified in the attached pages.

Interest is calculated through (specify date):

Principal:

Interest (optional): Total Arrearage:

SPOUSAL SUPPORT:

FAMILY SUPPORT:

UNREIMBURSED

MEDICAL EXPENSES:

UNREIMBURSED

CHILD CARE EXPENSES:

OTHER (specify):

Submitted by:

Other (specify):

MEDICAL SUPPORT:

$ $

www.courtinfo.ca.gov

Oran

341 The Cit

Drive

Oran

e, CA 92868

Lamoreaux Justice Center

PETITIONER/PLAINTIFF:

CASE NUMBER:

RESPONDENT/DEFENDANT:

OTHER PARENT:

PAYMENT HISTORY FOR

(check one):

Spousal

June

March

May

AMOUNT

ORDERED

January

February

April

July

PAYMENT HISTORY ATTACHMENT

(Family Law—Governmental—Uniform Parentage Act)

Family Code, §§ 5230.5,

17524 (a), 17526(c)

Form Approved for Optional Use

Judicial Council of California

FL-421 [Rev. July 1, 2003]

FL-421

Child Unreimbursed child care

Unreimbursed medical Other

(specify):

Year Year Year

AMOUNT

ORDERED

AMOUNT

ORDERED

AMOUNT

PAID

AMOUNT

PAID

AMOUNT

PAID

August

September

October

November

December

TOTAL

June

March

May

AMOUNT

ORDERED

January

February

April

July

Year Year Year

AMOUNT

ORDERED

AMOUNT

ORDERED

AMOUNT

PAID

AMOUNT

PAID

AMOUNT

PAID

August

September

October

November

December

TOTAL

Page 1 of ________

MedicalFamily

www.courtinfo.ca.gov

PAYMENT HISTORY ATTACHMENT

(Family Law—Governmental—Uniform Parentage Act)

FL-421 [Rev. July 1, 2003]

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.

June

March

May

AMOUNT

ORDERED

January

February

April

July

Year Year

AMOUNT

ORDERED

AMOUNT

PAID

AMOUNT

PAID

August

September

October

November

December

TOTAL

2000 2001

100

1,200 600

1,200

400

100

Child

June

March

May

AMOUNT

ORDERED

January

February

April

July

AMOUNT

PAID

August

September

October

November

December

TOTAL

100

1,200 600

100

Spousal

100

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.

UNREIMBURSED CHILD CARE, MEDICAL, OR OTHER EXPENSES:

June

March

May

AMOUNT

ORDERED

January

February

April

July

Year

AMOUNT

PAID

August

September

October

November

December

TOTAL

2001

50% ($200)

$400 150

Unreimbursed child care expenses

50% ($200)

100

June

March

May

AMOUNT

ORDERED

January

February

April

July

Year

AMOUNT

PAID

August

September

October

November

December

TOTAL

2001

50% ($200)

$237.50 0

Unreimbursed medical expenses

50% ($200)

50% ($75)

Petitioner/Plaintiff

Defendant/Respondent

CASE NUMBER

Form MC-031

I request reimbursement for 50% of these expenses, which

are supported by copies of bills, receipts, and other proof

of expense.

01/04/01

01/08/01

02/15/01

04/26/01

01/02

Dr. Adams

Dr. Lee, D.D.S.

02/02

03/02

04/02

$45.00

$155.00

AB X-ray Inc. $200.00

Exhibit A

Exhibit B

Exhibit C

Exhibit DKids Therapy $75.00

Child care expenses:

ABC School

50% ($200)

I declare under penalty of perjury under the laws of the State

of California that the foregoing is true and correct.

Form MC-031

ATTACHED DECLARATION

(SIGNATURE OF DECLARANT)(TYPE OR PRINT NAME)

Exhibit E

. . . . . . . . . . . . . . . . . . . . . . . . . . .

Form Approved for Optional Use

Judicial Council of California

MC-031 [Rev. July 1, 2005]

ATTACHED DECLARATION

PLAINTIFF/PETITIONER:

CASE NUMBER:

DEFENDANT/RESPONDENT:

MC-031

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

DECLARATION

Date:

(SIGNATURE OF DECLARANT)

(TYPE OR PRINT NAME)

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

Plaintiff

Other (Specify):

Defendant

Attorney for

Petitioner

Respondent

Page 1 of 1

FL-335

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):

FOR COURT USE ONLY

CASE NUMBER:

PROOF OF SERVICE BY MAIL

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

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.

My residence or business address is:

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

by enclosing them in an envelope AND

a. depositing the sealed envelope with the United States Postal Service with the postage fully prepaid.

The envelope was addressed and mailed as follows:

Name of person served:

Date mailed:

Place of mailing (city and state):

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)

Page 1 of 1

Form Approved for Optional Use

Judicial Council of California

FL-335 [Rev. January 1, 2012]

PROOF OF SERVICE BY MAIL

Code of Civil Procedure, §§ 1013, 1013a

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.

Address:b.

www.courts.ca.gov

PETITIONER/PLAINTIFF:

RESPONDENT/DEFENDANT:

OTHER PARENT/PARTY:

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

STREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

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.)

HEARING DATE:

DEPT.:

HEARING TIME:

FAX NO. (Optional):

E-MAIL ADDRESS (Optional):

ATTORNEY FOR (Name):

TELEPHONE NO.:

(If applicable, provide):

Oran

341 The Cit

Drive

Oran

e, CA 02868

Lamoreaux Justice Center

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:

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.

Third box, left side: Print the names of the petitioner/plaintiff, respondent/defendant, 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.

You cannot serve a temporary restraining order by mail. You must serve those documents by personal service.

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.

Print your home or business address.

List the name of each document that you mailed (the exact names are listed on the bottoms of the forms).

Check this box if you put the documents in the regular U.S. mail.

Check this box if you put the documents in the mail at your place of employment.

Print the name you put on the envelope containing the documents.

Print the address you put on the envelope containing the documents.

Print the date that you put the envelope containing the documents in the mail.

Print the city and state you were in when you mailed the envelope containing the documents.

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 law facilitator in your county.

INFORMATION SHEET FOR PROOF OF SERVICE BY MAIL

FL-335-INFO [New January 1, 2012]

Page 1 of 1

First box, left side: In this box print the name, address, and phone number of the person for whom you are serving the

Second box, right side: Print the case number in this box. This number is also stated on the documents you are serving.

4. a.

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).

Third box, right side: Print the hearing date, time, and department. Use the same information that is on the documents

you are serving.

FL-335-INFO

Code of Civil Procedure, §§ 1013, 1013a

www.courts.ca.gov

Use the same address for the court that is on the documents you are serving.

FL-334

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

CASE NUMBER:

Page 1 of 2

Form Approved for Optional Use

Judicial Council of California

FL-334 [New January 1, 2012]

Family Code, §§ 215, 17404, 17406

www.courts.ca.gov

PETITIONER/PLAINTIFF:

RESPONDENT/DEFENDANT:

OTHER PARENT/PARTY:

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

STREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

petitioner1. I am the attorney for respondent

Code of Civil Procedure, §§ 1013, 1013a;

DECLARATION REGARDING ADDRESS VERIFICATION—

POSTJUDGMENT REQUEST TO MODIFY A CHILD CUSTODY,

VISITATION, OR CHILD SUPPORT ORDER

DECLARATION REGARDING ADDRESS VERIFICATION—

POSTJUDGMENT REQUEST TO MODIFY A CHILD CUSTODY,

VISITATION, OR CHILD SUPPORT ORDER

Before the request was served on the other party by mail, I verified in the previous 30 days that the other party’s current

current residence or office address is (specify):

FAX NO. (Optional):

E-MAIL ADDRESS (Optional):

ATTORNEY FOR (Name):

TELEPHONE NO.:

The request is to modify a judgment or permanent orders for child custody, visitation, or child support.

Date:

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

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

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.

other party in this matter.

(1)

(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):

I contacted the other party directly within the past 30 days and he or she gave me the above address.

I have been at that address in connection with a custody and visitation or other matter within the past 30 days.

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):

I can confirm that the above address is the other party’s current residence or office address because (specify):

(2)

(3)

Continued in Attachment 3b(6).

It is the office address that he or she last gave on a document filed with the court in this case which was also

served on me as a party in the case.

(4)

other parent

providing services in the case. Service of the request solely to modify child support will be made on other party by serving

The request is to modify a judgment or permanent order only for child support and a local child support agency is

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).

Oran

341 The Cit

Drive

Oran

e, CA 92868

Lamoreaux Justice Center

NOTICE AND SERVICE INFORMATION

Page 2 of 2

FL-334 [New January 1, 2012]

CASE NUMBER:

DECLARATION REGARDING ADDRESS VERIFICATION—

POSTJUDGMENT REQUEST TO MODIFY A CHILD CUSTODY,

VISITATION, OR CHILD SUPPORT ORDER

PETITIONER/PLAINTIFF:

RESPONDENT/DEFENDANT:

OTHER PARTY:

FL-334

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.