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SHC-FLFO-01 (Rev. 01/10/2018)
FLFO ONE-ON-ONE ASSISTANCE PACKET
CHECKLIST
□ You must have an open, active case with Orange County Child
Support Services (CSS).
□ Complete the attached forms.
□ Complete your Declaration explaining what you are requesting
and why. If you are requesting a modification of support, you
must explain what has changed since the last order was made
(loss of job, increase or decrease in parenting time, etc.).
□ Bring proof of income: pay stubs from the last 2 months; if
self-employed, Schedule C from your last federal tax return or
Profit and Loss statements from the last 2 years; unemployment
benefits; disability benefits; Social Security benefits; any other
source of income showing year-to-date earnings. Failure to
provide proof of income may result in your request being
denied.
□ If requesting review of license denial, bring denial letter from CSS.
□ If requesting payment on child support arrears or waiver of
unassigned arrears, bring Case Balance Detail from CSS showing
arrears balance.
□ Other documentation to support your request.
Please use a BLACK ink pen.
Superior Court Case Number:___________________________________
CSS Case Number:___________________________________________
*Facilitator staff will not provide legal advice.
SUPERIOR COURT OF CALIFORNIA
COUNTY OF ORANGE
SELF-HELP CENTER
1 – Rev. 10/14/2016
REGISTRATION PACKET
FLFO One-on-One Assistance
INFORMATION ABOUT YOU AND THE OTHER PARENT
Your full name as it appears in the court records:
.
First name Middle name Last name
The Other Parent’s full name as it appears in the court records:
.
First name Middle name Last name
Your current address: .
.
A phone number where the Court can contact you: .
The Other Parent’s current address: .
.
Please list all cases and case numbers below:
Divorce [ ] No [ ] Yes (Case # and County )
Domestic Violence [ ] No [ ] Yes (Case # and County )
Juvenile Court [ ] No [ ] Yes (Case # and County )
Child Support [ ] No [ ] Yes (Case # and County )
Other [ ] No [ ] Yes (Case # and County )
Please list all MINOR children of this relationship below:
INFORMATION ABOUT YOUR CURRENT ORDERS (IF ANY)
You must provide the information below about your most recent court orders.
CHECK BOX(ES) FOR ISSUE(S) YOU ARE ADDRESSING.
□ CHILD SUPPORT
Order Date: ____________
Ordering: $________________________________________________________________________________
□ SPOUSAL SUPPORT
Order Date: ____________
Ordering: $________________________________________________________________________________
□ PAYMENT ON ARREARS
Order Date: ____________
Ordering: $________________________________________________________________________________
First Name Middle Name Last Name Date of Birth
2 – Rev. 10/14/2016
*For average monthly amount, add up all income of that type from the last 12 months and divide total by 12.
WHAT ORDERS WOULD YOU LIKE NOW?
□ C/S Amount (if not guideline): $________________________________________________________
□ S/S Amount: $_______________________________________________________________________
□ Payment on Arrears: $________________________________________________________________
DECLARATION
Complete the Attached Declaration form (MC-031) telling the Court what you are requesting and why.
The Court’s Self-Help webpage has a presentation on how to write a declaration for court purposes,
available at the following link: http://www.occourts.org/self-help/resources/shresources.html. On this
page, scroll down to Educational Videos/Other and click on “Writing a Declaration for the Court.”
WRITE YOUR DECLARATION ON
FORM MC-031 – THE LAST PAGE OF THIS
PACKET.
3 – Rev. 10/14/2016
*For average monthly amount, add up all income of that type from the last 12 months and divide total by 12.
INCOME AND EXPENSE DECLARATION WORKSHEET
INFORMATION ABOUT YOUR EMPLOYMENT
A. Employment:
I am currently: employed unemployed self-employed (if self-employed, go to B.)
(Give information on your current job or, if you’re unemployed, your most recent job.)
Employer: ______________________________________________________________________
Employer’s address: ______________________________________________________________
Employer’s phone number: ________________________________________________________
Occupation: ____________________________________________________________________
Date job started: _________________________________________________________________
If unemployed, date job ended: _____________________________________________________
I work about hours per week.
I get paid $ gross (before taxes): per month per week per hour
If you have more than one job, provide information below:
Employer: ______________________________________________________________________
Employer’s address: ______________________________________________________________
Employer’s phone number: ________________________________________________________
Occupation: ____________________________________________________________________
Date job started: _________________________________________________________________
I work about hours per week.
I get paid $ gross (before taxes): per month per week per hour
B. Self-employment:
Type: owner/sole proprietor business partner other: _______________________________________
Number of years in this business: _____ Name of business: __________________________________________
Type of business: ___________________________________________________________________________
Income after business expenses: Last Month: $___________ Average Monthly*: $___________
INFORMATION ABOUT YOUR AGE AND EDUCATION
How old are you? _____ (in years)
Did you complete high school or the equivalent?
Yes No (If No, highest grade completed:_________)
How many years of college have you completed? ______ Specify degree obtained: ______________________
How many years of graduate school have you completed? _______ Specify degree obtained: _______________
Do you have any professional/occupational license(s)? Yes No (Specify: _______________________)
Do you have any vocational training?
Yes No (Specify: ____________________________________)
INFORMATION ABOUT YOUR TAXES
Last tax year you filed your income tax returns: ______________________
What is your current tax filing status? single head of household married, filing separately
married, filing jointly with: (name) __________________________________________________________
State(s) where you file tax returns:
California Other: _________________________________________
How many exemptions (including yourself) do you claim on your federal tax return? _____________________
Do you know the other parent’s monthly income? Yes No If yes, how much? $___________ per month.
Based on: Personal knowledge Child Support Calculation Other: ___________________________
_________________________________________________________________________________________
4 – Rev. 10/14/2016
*For average monthly amount, add up all income of that type from the last 12 months and divide total by 12.
INFORMATION ABOUT YOUR INCOME, DEDUCTIONS, AND ASSETS
Income (gross, before taxes):
Type and Amounts ($): Last Month Average Monthly*
Salary/Wages: ____________________ ____________________
Overtime: ____________________ ____________________
Commissions/Bonuses: ____________________ ____________________
Pension/Retirement Fund: ____________________ ____________________
Social Security retirement (not SSI): ____________________ ____________________
Unemployment: ____________________ ____________________
Workers’ compensation: ____________________ ____________________
Spousal/Partner Support (this relationship): ____________________ ____________________
Spousal/Partner Support (different relationship): ____________________ ____________________
Other: ____________________ ____________________ ____________________
Are you currently receiving Public Assistance?
Yes No
Type and Amounts ($): Last Month Average Monthly*
TANF: ____________________ ____________________
SSI: ____________________ ____________________
County Assistance/General Relief: ____________________ ____________________
Other: _____________________ ____________________ ____________________
Food Stamps: ____________________ ____________________
Investment income, rental property, trust):
Type and Amounts ($): Last Month Average Monthly*
Dividends/Interest: ____________________ ____________________
Rental property: ____________________ ____________________
Trust: ____________________ ____________________
One-time money in last 12 months (lottery winnings, inheritance):
Type: ____________________________________________________________________________________
Amount $__________________________
Change in income:
How has your financial situation changed over the last 12 months? ____________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Deductions (last month):
Union dues: $_______________
Required retirement payments (not 401(k)): $_______________
Medical/dental/other health insurance premium: $_______________
Child support for other children: $_______________ (Is amount court-ordered? Yes No. If Yes,
provide court case number(s): _________________________________________________________________.
Is amount paid directly to other parent? Yes No)
Spousal/Partner support for other marriage/domestic partnership: $_______________
Necessary job-related expenses not reimbursed by employer: $________ (explain: _______________________
_________________________________________________________________________________________)
5 – Rev. 10/14/2016
*For average monthly amount, add up all income of that type from the last 12 months and divide total by 12.
Assets:
Cash, bank or other financial institution accounts: $_______________
Stocks, bonds or other assets that can be easily sold: $_______________
Real Property (fair market value less balance owed): $_______________
Personal Property (e.g., automobile; fair market value less balance owed): $_______________
INFORMATION ABOUT YOUR HOUSEHOLD AND EXPENSES
The following people live with me (people you support or who support you):
Name Age Relationship to That person’s gross Pays some of the
you (spouse, etc.) monthly income ($) household expenses?
1. _____________________ ____ ________________ _____________ Yes No
2._____________________ ____ ________________ _____________ Yes No
3. _____________________ ____ ________________ _____________ Yes No
4. _____________________ ____ ________________ _____________ Yes No
5. _____________________ ____ ________________ _____________ Yes No
Average MONTHLY expenses: Estimated expenses Actual expenses Proposed Needs
a. Home h. Laundry & cleaning $ ________
Rent or
If
Mortgage:
Property
tax:
Homeowner’s/
Renter’s
Insurance
Mortgage
(Principal):
(Interest):
$
$
$
$
$
_________
(________)
(________)
__________
___________
i. Clothes $ ________
b. Health care costs not
covered by insurance
$ _________ j. Education $ _________
c. Child Care $ _________ k. Entertainment, gifts,
vacation
$ _________
d. Groceries, household
supplies
$ _________ l. Auto expenses &
transportation
(insurance, gas, repairs,
bus)
$ _________
e. Eating out $ _________ m. Insurance (life, accident, etc.
do not include auto, home,
health)
$ _________
f. Utilities (gas, electric, water,
trash)
$ _________ n. Savings and investments $ _________
g. Telephone, cell phone,
e-mail
$ _________ o.
q.
Charitable contributions
Other __________________
_______________________
$
$
_________
_________
6 – Rev. 10/14/2016
*For average monthly amount, add up all income of that type from the last 12 months and divide total by 12.
Installment payments and debts not listed above (loans, credit cards, etc.):
Paid to For Monthly Balance Date of Last
Amount ($) ($) Payment
1._____________________ __________________ _________ _________ ______________
2._____________________ __________________ _________ _________ ______________
3._____________________ __________________ _________ _________ ______________
4._____________________ __________________ _________ _________ ______________
5._____________________ __________________ _________ _________ ______________
6._____________________ __________________ _________ _________ ______________
INFORMATION ABOUT YOUR CHILDREN IN THIS CASE
How many children do you have with the other parent in this case? ___________
Percentage of time the children spend with: You_____% Other Parent______%
If you do not know the percentage, specify your parenting schedule: _________________________
________________________________________________________________________________
________________________________________________________________________________
Health insurance:
Do you have health insurance available for the children through your employment? Yes No
If Yes, provide name and address of insurance company: __________________________________
________________________________________________________________________________
What is the monthly cost for the children’s health insurance? $______________________________
Additional expenses for the children (child care, uncovered health care costs, travel expenses,
educational/special needs)**:
Type: _________________________________________ Monthly Amount $__________________
Type: _________________________________________ Monthly Amount $__________________
Type: _________________________________________ Monthly Amount $__________________
Type: _________________________________________ Monthly Amount $__________________
Type: _________________________________________ Monthly Amount $__________________
**Bring proof of these expenses to attach to your filing.
INFORMATION ABOUT SPECIAL HARDSHIPS
Extraordinary health expenses: Monthly Amount $ ____________ How many months? ______
Major losses not covered by insurance (fire, theft, etc.): Monthly Amount $ __________ How
many months? ______
Expenses for biological or adopted children from other relationships living with you:
Child’s Name Age Amount of expense How many Amount of child
per month ($) months? support received per
month ($)
1. _____________________ ____ ________________ ________ __________________
2._____________________ ____ ________________ ________ __________________
3. _____________________ ____ ________________ ________ __________________
4. _____________________ ____ ________________ ________ __________________
Adopted for Optional Use
L-1400 [New 02/17] DECLARATION IN SUPPORT OF MODIFICATION OF CHILD SUPPORT Page 1 of 3
PARTY WITHOUT ATTORNEY OR ATTORNEY (Name and Address):
TELEPHONE NO.: FAX NO. (Optional):
E-MAIL ADDRESS (Optional):
ATTORNEY FOR (Name): BAR NO.:
FOR COURT USE ONLY
SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE
JUSTICE CENTER:
Central – 700 Civic Center Drive West, Santa Ana, CA 92701-4045
Lamoreaux – 341 The City Drive South, Orange, CA 92868-3205
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT/PARTY:
DECLARATION IN SUPPORT OF MODIFICATION OF CHILD
SUPPORT
CASE NUMBER:
I am requesting 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 __________. The reason I am not working there is 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.
I tried to find
work at my previous rate of pay but was unable to.
b. I am still employed at the same place I was when the last 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. Change in child custody and/or timeshare with children in this case
a. I now have primary custody substantial increased timeshare with the children in this case. The children
are now with me as follows: _____________________________________________________________________
___________________________________________________________________________________________.
Timeshare is estimated to be: _____% to me and _____% to the other parent. Timeshare was calculated by
Family Court Services the court me.
b. My child, ______________________________, is now emancipated as a result of attaining the age 18 and
not in high school
attaining the age 19 married in the military judicial decree. I request that support
for that child be terminated.
✔
Adopted for Optional Use
L-1400 [New 02/17] DECLARATION IN SUPPORT OF MODIFICATION OF CHILD SUPPORT Page 2 of 3
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT:
4. Disability and decrease in earnings and/or loss of income
I am currently disabled. My disability began on _______________ and consists of the following medical/psychological
problems: ___________________________________________________________________________________.
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: ______________.
I expect to start receiving benefits on or about _______________ in the amount of $ __________ monthly. Until I
start to receive these benefits, I ask the court to 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 policy. The amount I
receive monthly is $ __________.
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 my children from Social Security as a result of my disability be offset against my
child support order entered, pursuant to Family Code section 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.
5. Change in income or ability to earn of the other parent
Since the last order for child support was made, the other parent:
a. has become employed, earning $ __________ per hour, working __________ hours per week.
b. has received an increase in earnings and now earns $ __________ per month.
c. now has the ability to obtain employment and earn at least $ __________ per month.
6. Financial hardship
Since the last order was made, I have sustained the following financial hardship(s):
a. Statutory hardship –
1. Expenses of natural or adopted children in the home (FC § 4071(a)(2)). I provide support for the following
natural or adopted minor children who reside in my home: __________________________________________.
2. Extraordinary health expenses and uninsured catastrophic losses (FC § 4071(a)(1)):
________________________________________________________________________________________.
b. Low income adjustment - I request that the court order a low income adjustment in this case because I net
less than $1,500 per month, taking into consideration all allowable deductions and hardships.
c. Court discretion - I request that the court use its discretion and deviate from the guideline amount because
application of the guideline formula would be unjust or inappropriate due to the special circumstances in my case.
The facts supporting the special circumstances in my case are: _________________________________________
___________________________________________________________________________________________.
Adopted for Optional Use
L-1400 [New 02/17] DECLARATION IN SUPPORT OF MODIFICATION OF CHILD SUPPORT Page 3 of 3
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT:
7. Recent release from incarceration and decrease in earnings and/or current unemployment
I was released from incarceration on __________. I was incarcerated from __________ to __________. I am
currently unemployed as a result of my incarceration and am actively looking for work. A list of my job contacts is
attached or will be provided at the hearing. I have no current income. I am asking the court to reduce my child support
to zero until I find employment. I am willing to return to court for review hearings as necessary.
I am in a recovery
program called _____________________________________ and have been there since __________. The program
requirements are ________________________________________________________________________. I am not
allowed to work for the first ________ weeks/months. Thereafter I can work as follows: ________________________
______________________________________________________________________________________________.
I have attached verification of my enrollment and participation in this program. I am asking the court to reduce my
child support to zero until I find employment. I am willing to return to court for review hearings as necessary.
8. Other change of circumstance: ________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
9. I request child support be modified and set at zero for any full calendar months in which the parent ordered to
pay support is incarcerated or receiving SSI, and has no other assets or income. For all other periods, I
request current support remain in effect until modified by court order.
10. Other information I want the court to know concerning child support in my case that supports my request as
set forth above: ________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
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)
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
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Completed 8 February 2021

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