FL-625 - Stipulation and Order (Governmental)

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Stipulation and Order (Governmental)

Text

Form ID: FL-625
Title: Stipulation and Order (Governmental)
Effective Date: 2020-01-01
Mandatory Form: yes
Languages: 汉语, 한국어, español, Tagalog, Tiếng Việt
Info Page: https://selfhelp.courts.ca.gov/jcc-form/FL-625
Primary Download URL: https://www.courts.ca.gov/documents/fl625.pdf
Alternate Download URLs: https://www.courts.ca.gov/documents/fl625c.pdf, https://www.courts.ca.gov/documents/fl625k.pdf, https://www.courts.ca.gov/documents/fl625s.pdf, https://www.courts.ca.gov/documents/fl625t.pdf, https://www.courts.ca.gov/documents/fl625v.pdf
Form Detail Page:
Stipulation and Order (Governmental)
(FL-625)
Parents and the local child support agency tell the court about their agreement for child support.
Get form FL-625
汉语
Get form FL-625 in Chinese Simplified
(Chinese Simplified)
한국어
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(Korean)
español
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(Spanish)
Tagalog
Get form FL-625 in Tagalog
(Tagalog)
Tiếng Việt
Get form FL-625 in Vietnamese
(Vietnamese)
Effective: January 1, 2020
PDF Text:
Form Adopted for Alternative Mandatory Use 
Instead of Form FL-692  
Judicial Council of California  
 FL-625 [Rev. January 1, 2020]
STIPULATION AND ORDER 
(Governmental) 
Family Code, §§ 17400, 17402, 
17404, 17430 
www.courts.ca.gov
E-MAIL ADDRESS:
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
RESPONDENT/DEFENDANT:
OTHER PARENT/PARTY:
PETITIONER/PLAINTIFF:
FOR COURT USE ONLY
FL-625
FAX NO.:
ATTORNEY FOR (name):
TELEPHONE NO.:
GOVERNMENTAL AGENCY (under Family Code, §§ 17400, 17406):
This matter proceeded as follows:
a.
b.
2.
The parties agree that
1.
c.
3.
c.
All orders previously made in this action remain in full force and effect except as specifically modified below.
per month.
(1) We have been fully informed of the guideline amount of support; we agree voluntarily to child support of:
per month; the agreement is in the best interest of the children; the needs of the children
will be met adequately by the agreed amount; the children are not receiving public assistance; no application 
for public assistance is pending; and application of the guideline would be unjust and inappropriate in this 
case. We understand that if the order is below the guideline, no change of circumstances need be shown for 
the court to raise this order to the guideline amount. If the order is above the guideline, a change of 
circumstances will be required to modify this order.
Other rebutting factors (specify):(2)
$
The amount of support payable by the parent ordered to pay support as calculated under the guideline is: $
(1) 
(2) Petitioner/plaintiff present   
(3)
(4)
(6)
Other parent/party present
Local child support agency (Family Code, §§ 17400, 17406) by (name):(5)
Respondent/defendant present   
Judicial Officer:
Attorney present (name):
Attorney present (name):
Attorney present (name):
Dept:Date:
a.
b.
Other (specify):
This order is based on the attached documents (specify):
The attached computer printout shows the parents’ incomes and percentage of time each parent spends with the 
children. The printout, which shows the calculation of child support payable, will become the court’s findings.
The parent ordered to pay support is the other parent/party.respondent/defendantpetitioner/plaintiff
By court hearing, appearances as follows:
By written stipulation without court appearance.
The guideline amount should be rebutted because of the following:
We agree to guideline support.
STIPULATION AND ORDER
CASE NUMBER:
NOTICE:  Any party required to pay child support must pay interest on overdue amounts at the legal rate, which is  currently 
10 percent per year.
Page 1 of 4

FL-625 [Rev. January 1, 2020] STIPULATION AND ORDER 
(Governmental) 
Page 2 of 4
FL-625
RESPONDENT/DEFENDANT:
OTHER PARENT/PARTY:
PETITIONER/PLAINTIFF: CASE NUMBER:
Date of birthName of child Monthly support amount
d.3.
(3)
Any support ordered will continue until further order of court, unless terminated by operation of law.
(4)
day of each monthFor a total of: $ payable on the:
beginning (date):
Other (specify):
(5)
(1)
e.
(2)
coverage for the children if available at no or reasonable cost and keep the local child support agency informed of the 
availability of the coverage (the cost is presumed to be reasonable if it does not exceed 5 percent of gross income to add 
a child); (2) if health insurance is not available, provide coverage when it becomes available; (3) within 20 days of the local 
child support agency’s request, complete and return a health insurance form; (4) provide to the local child support agency 
all information and forms necessary to obtain health-care services for the children; (5) present any claim to secure 
payment or reimbursement to the other parent or caretaker who incurs costs for health-care services for the children; and 
(6) assign any rights to reimbursement to the other parent or caretaker who incurs costs for health-care services for the 
children. The parent ordered to provide health insurance must seek continuation of coverage for the child after the child 
attains the age when the child is no longer considered eligible for coverage as a dependent under the insurance contract, 
if the child is incapable of self-sustaining employment because of a physically or mentally disabling injury, illness, or 
condition and is chiefly dependent upon the parent providing health insurance for support and maintenance.
The parent ordered to pay support The parent receiving support   (1) must provide and maintain health insurance
The parent ordered to pay support must pay current child support as follows:
Mandatory additional child support.
f.
(2) Interest is not included and is not waived.
day of each monthon the:
Interest accrues on the entire principal balance owing and not on each installment as it becomes due.
Child support: $ Spousal support: $ Family support: $
Payable: $
beginning (date):
(3)
(4)
(1)
The parent ordered to pay support owes support arrears as follows, as of (date):
Payments must be made to the other parent State Disbursement Unit child-care provider.
The parent ordered to pay support must pay reasonable uninsured health-care costs for the children, as follows: 
Payments must be made to the other parent State Disbursement Unit health-care provider.
The parent ordered to pay support must pay additional monthly support for reasonable child-care costs, as follows: 
(b)
(a)
(specify amount): $One-half or % or per month of the costs
(specify amount): $One-half or % or per month of the costs
The low-income adjustment applies.
The low-income adjustment does not apply because (specific reasons):

FL-625
RESPONDENT/DEFENDANT:
OTHER PARENT/PARTY:
PETITIONER/PLAINTIFF: CASE NUMBER:
FL-625 [Rev. January 1, 2020] STIPULATION AND ORDER 
(Governmental) 
Page 3 of 4
The parents must notify the local child support agency in writing within 10 days of any change in residence or employment.
The Notice of Rights and Responsibilities (Health-Care Costs and Reimbursement Procedures) and Information Sheet on  
Changing a Child Support Order (form FL-192) is attached.
m.
l.
If "The parent ordered to pay support" box is checked in item 3e, a health insurance coverage assignment must issue. k.
n.
o.
(SIGNATURE OF ATTORNEY FOR LOCAL CHILD SUPPORT AGENCY)
(SIGNATURE OF PETITIONER)
(SIGNATURE OF ATTORNEY FOR PETITIONER)
3.
(SIGNATURE OF RESPONDENT)
(SIGNATURE OF ATTORNEY FOR RESPONDENT)
No provision of this judgment may operate to limit any right to collect the principal (total amount of unpaid support) or to charge  
and collect interest and penalties as allowed by law. All payments ordered are subject to modification.
An Income Withholding for Support (form FL-195/OMB No. 0970-0154) will issue.
g.
h.
i.
j. In the event that there is a contract between a party receiving support and a private child support collector, the party ordered to  
pay support must pay the fee charged by the private child support collector. This fee must not exceed 33 1/3 percent of the total 
amount of past due support nor may it exceed 50 percent of any fee charged by the private child support collector. The money  
judgment created by this provision is in favor of the private child support collector and the party receiving support, jointly.
All payments, unless specified in item 3d(1) above, must be made to the State Disbursement Unit at the address listed below  
(specify address):  
The following person (the "other parent/party") is added as a party to this action (name):
Other (specify):
Date:
(TYPE OR PRINT NAME)
Date:
(TYPE OR PRINT NAME)
Date:
[TYPE OR PRINT NAME)
Date:
(TYPE OR PRINT NAME)
Date:
(TYPE OR PRINT NAME)

FL-625
RESPONDENT/DEFENDANT:
OTHER PARENT/PARTY:
PETITIONER/PLAINTIFF: CASE NUMBER:
FL-665 [Rev. January 1, 2020] STIPULATION AND ORDER 
(Governmental) 
Page 4 of 4
DECLARATION OF PERSON PROVIDING INTERPRETATION/TRANSLATION:  The party/parties indicated below is/are unable to  
read or understand this Stipulation and Order because
's primary 
I certify under penalty of perjury under the laws of the State of California that I am competent to interpret or translate in the primary  
language indicated above and that I have, to the best of my ability, read to, interpreted for, or translated for the above-named party the  
Stipulation and Order in the party's primary language. The above-named party said that the terms of this Stipulation and Order were 
understood by that party before it was signed.
(SIGNATURE) (SIGNATURE)
and the party has has not   read the form 
stipulation translated into this language.
and the party has has not   read the form 
stipulation translated into this language.
ORDER
THE COURT SO ORDERS.
JUDICIAL OFFICER
SIGNATURE FOLLOWS LAST ATTACHMENT
4.
(SIGNATURE OF OTHER PARENT)
(SIGNATURE OF ATTORNEY FOR OTHER PARENT)
Date:
Number of pages attached:
(Insert name) 
language is (specify):
's primary (Insert name) 
language is (specify):
Date:
(TYPE OR PRINT NAME)
Date:
(TYPE OR PRINT NAME)
Date:
(TYPE OR PRINT NAME)
Date:
(TYPE OR PRINT NAME)

Retrieval chunks

• #1

  Form ID: FL-625 Title: Stipulation and Order (Governmental) Effective Date: 2020-01-01 Mandatory Form: yes Languages: 汉语, 한국어, español, Tagalog, Tiếng Việt Info Page: https://selfhelp.courts.ca.gov/jcc-form/FL-625 Primary Download URL: https://www.courts.ca.gov/documents/fl625.pdf Alternate Download URLs: https…

• #2

  circumstances will be required to modify this order. Other rebutting factors (specify):(2) $ The amount of support payable by the parent ordered to pay support as calculated under the guideline is: $ (1) (2) Petitioner/plaintiff present (3) (4) (6) Other parent/party present Local child support agency (Famil…

• #3

  (6) assign any rights to reimbursement to the other parent or caretaker who incurs costs for health-care services for the children. The parent ordered to provide health insurance must seek continuation of coverage for the child after the child attains the age when the child is no longer considered eligible for cover…

• #4

  (SIGNATURE OF PETITIONER) (SIGNATURE OF ATTORNEY FOR PETITIONER) 3. (SIGNATURE OF RESPONDENT) (SIGNATURE OF ATTORNEY FOR RESPONDENT) No provision of this judgment may operate to limit any right to collect the principal (total amount of unpaid support) or to charge and collect interest and penalties as allowed by…

• #5

  (SIGNATURE OF OTHER PARENT) (SIGNATURE OF ATTORNEY FOR OTHER PARENT) Date: Number of pages attached: (Insert name) language is (specify): 's primary (Insert name) language is (specify): Date: (TYPE OR PRINT NAME) Date: (TYPE OR PRINT NAME) Date: (TYPE OR PRINT NAME) Date: (TYPE OR PRINT NAME)