FL-684 - Request for Order and Supporting Declaration (Governmental)

Summary

Request for Order and Supporting Declaration (Governmental)

Text

Form ID: FL-684
Title: Request for Order and Supporting Declaration (Governmental)
Effective Date: 2010-01-01
Mandatory Form: yes
Languages: 汉语, 한국어, español, Tagalog, Tiếng Việt
Info Page: https://selfhelp.courts.ca.gov/jcc-form/FL-684
Primary Download URL: https://www.courts.ca.gov/documents/fl684.pdf
Alternate Download URLs: https://www.courts.ca.gov/documents/fl684c.pdf, https://www.courts.ca.gov/documents/fl684k.pdf, https://www.courts.ca.gov/documents/fl684s.pdf, https://www.courts.ca.gov/documents/fl684t.pdf, https://www.courts.ca.gov/documents/fl684v.pdf
Form Detail Page:
Request for Order and Supporting Declaration (Governmental)
(FL-684)
Tells you why the local child support agency is requesting new orders in your case.
Get form FL-684
汉语
Get form FL-684 in Chinese Simplified
(Chinese Simplified)
한국어
Get form FL-684 in Korean
(Korean)
español
Get form FL-684 in Spanish
(Spanish)
Tagalog
Get form FL-684 in Tagalog
(Tagalog)
Tiếng Việt
Get form FL-684 in Vietnamese
(Vietnamese)
Effective: January 1, 2010
PDF Text:
FL-684
CASE NUMBER:PETITIONER / PLAINTIFF:
RESPONDENT / DEFENDANT:
OTHER PARENT:
(THIS IS A REQUEST, NOT AN ORDER)
I REQUEST THE FOLLOWING ORDERS FOR: 
Date of birth Name of child Date of birth
1. PARENTAGE.  If not previously established, a judgment that you are the parent of the children named above.
2. CHILD SUPPORT.  Monthly child support based on the state guideline. (An Income Withholding for Support (FL-195/OMB No. 
0970-0154) will be issued.)
This is a request for a change to an existing order a.
(2)   ordering (specify):
b.  Child support to commence 
(2) effective (specify):
c.  Other (specify):
HEALTH INSURANCE COVERAGE 
If not previously ordered, an order that you provide health insurance for each child named above and an order that you 
complete the attached health insurance form and immediately return it to the local child support agency.
3.
NOTICE: Your employer or other person providing health insurance will be ordered to enroll the children in an appropriate 
health insurance plan if you are found to be the parent, and a National Medical Support Notice will be issued.
4. FEES AND COSTS Fees: $ Costs: $
5. PROPERTY RESTRAINT
Petitioner/plaintiff Other parentRespondent/defendant
be restrained from transferring, encumbering, hypothecating, concealing, or in any way disposing of the following property
(specify):
Page 1 of 2
Form Adopted for Mandatory Use 
Judicial Council of California 
FL-684 [Rev. January 1, 2010]
Family Code §§ 215, 3751, 3761, 
3900-3901, 4001-4062, 4007, 4009, 4014,REQUEST FOR ORDER AND SUPPORTING DECLARATION 
(Governmental) 4050-4076, 4200-4204, 7551,17304, 17400,
17402,17404, 17406,17422 
www.courtinfo.ca.gov
Name of child
(1)   filed on (date if known):
(1)  on the date this request was mailed or given to you.

CASE NUMBER:PETITIONER / PLAINTIFF:
RESPONDENT / DEFENDANT:
OTHER PARENT:
FL-684
6. OTHER (specify):
7. FACTS IN SUPPORT of this request are: 
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 REQUESTING THESE ORDERS)
Page 2 of 2FL-684 [Rev. January 1, 2010] REQUEST FOR ORDER AND SUPPORTING DECLARATION 
(Governmental)
contained in an attached declaration.

Retrieval chunks

• #1

  Form ID: FL-684 Title: Request for Order and Supporting Declaration (Governmental) Effective Date: 2010-01-01 Mandatory Form: yes Languages: 汉语, 한국어, español, Tagalog, Tiếng Việt Info Page: https://selfhelp.courts.ca.gov/jcc-form/FL-684 Primary Download URL: https://www.courts.ca.gov/documents/fl684.pdf Alterna…

• #2

  Judicial Council of California FL-684 [Rev. January 1, 2010] Family Code §§ 215, 3751, 3761, 3900-3901, 4001-4062, 4007, 4009, 4014,REQUEST FOR ORDER AND SUPPORTING DECLARATION (Governmental) 4050-4076, 4200-4204, 7551,17304, 17400, 17402,17404, 17406,17422 www.courtinfo.ca.gov Name of child (1) filed on (da…