PETITIONER: CASE NUMBER:
FL-170
RESPONDENT:
6.
a. The information in Declaration Under Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) (form FL-105)
b. There is an existing court order for custody/parenting time in another case in (county):
The case number is (specify):
Child custody and visitation (parenting time) should be ordered as set forth in the proposed Judgment (form FL-180).
The current custody and visitation (parenting time) previously ordered in this case, or the current schedule is (specify):c.
has has not changed since it was last filed with the court. (If changed, attach updated form.)
Contained on Attachment 6c.
d.
Contained on Attachment 6d.
The facts that support the requested judgment are (In a default case, state your reasons below):
7.
a.
Child support should be ordered as set forth in the proposed Judgment (form FL-180).
If there are minor children, check and complete item (1) if applicable and item (2) or (3):
(1) Child support is being enforced in another case in (county):
The case number is (specify):
(2) The information in the child support calculation attached to the proposed judgment is correct based on my personal
knowledge.
(3) I request that this order be based on the Petitioner's Respondent’s earning ability. The facts in
support of my estimate of earning ability are (specify):
Continued on Attachment 7a(3).
b. Complete items (1) and (2) regarding public assistance.
(1) am receiving am not receiving intend to apply for public assistance for the child or children
listed in the proposed order.
I
(2) isTo the best of my knowledge, the other party is not receiving public assistance.
Petitioner Respondent is presently receiving public assistance, and all support should be made payable
to the local child support agency at the address set forth in the proposed judgment. A representative of the local child
support agency has signed the proposed judgment.
FL-170 [Rev. January 17, 2020]
DECLARATION FOR DEFAULT OR UNCONTESTED
DISSOLUTION OR LEGAL SEPARATION
Page 2 of 3
(Family Law)
8. Spousal, Partner, and Family Support (If a support order or attorney fees are requested, submit a completed Income and
Expense Declaration (form FL-150) unless a current form is on file. Include your best estimate of the other party’s income.
Check at least one of the following.)
a. I knowingly give up forever any right to receive spousal or partner support.
b. I ask the court to reserve jurisdiction to award spousal or partner support in the future to:
d. Spousal support or domestic partner support should be ordered as set forth in the proposed Judgment (form FL-180)
based on the factors described in:
c. I ask the court to terminate forever spousal or partner support for: Petitioner Respondent
Spousal or Partner Support Declaration Attachment (form FL-157)
written agreement
attached declaration (Attachment 8d)
e. Family support should be ordered as set forth in the proposed Judgment (form FL-180).
f. Other (specify):
d. This matter is proceeding as an uncontested action. Service of the final Declaration of Disclosure (form FL-140) is
mutually waived by both parties. A waiver provision executed by both parties under penalty of perjury is contained on the
Stipulation and Waiver of Final Declaration of Disclosure (form FL-144), in the settlement agreement or proposed
judgment, or in another, separate stipulation.
Petitioner Respondent
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