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

FOR COURT USE ONLY

FL-650

STATEMENT FOR REGISTRATION OF CALIFORNIA SUPPORT ORDER

CASE NUMBER:

Support Order

Order for Earnings Assignment

The local child support agency's statement to register 
is as follows:

a California support order

a California order for earnings assignment

1. 

The Obligor (the parent ordered to pay support) is

Respondent/Defendant

Petitioner/Plaintiff
Other parent

2. 

An endorsed filed copy of the most recent support order or earnings assignment (or a copy) is attached.

An affidavit or declaration of Obligor's payment history is attached.
A Declaration of Payment History (form FL-420) is attached.
The arrearage balance is unknown.

a.

.

b c

3. 

4. 

The local child support agency's post office address is (specify):

5. 

Obligor's last known place of residence or mailing address, or address in the records of the California Department of Motor
Vehicles, is (specify):

6. 

States and counties in which the original order for support or order for earnings assignment, and any modifications, are registered 
(specify):

None, or unknown.

1.

You have 20 days after the date of mailing of this Statement for Registration of California Support Order  to petition the 
court to cancel (vacate) this registration or for other relief.  (Family Code, § 5603.)  (See the accompanying document 
to determine the date of mailing.)

2.

The local child support agency may seek a health insurance coverage assignment enrolling the children in an
appropriate health insurance plan under Family Code section 3761.

NOTICE TO OBLIGOR

Form Adopted for Mandatory Use
Judicial Council of California
FL-650 [Rev. January 1,  2003]

STATEMENT FOR REGISTRATION
OF CALIFORNIA SUPPORT ORDER
(Governmental)

Page 1 of 1

Family Code, § 5601
www.courtinfo.ca.gov.

TELEPHONE NO.:

FAX NO.:

SUPERIOR COURT OF CALIFORNIA, COUNTY OF 

STREET ADDRESS:

MAILING  ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

PETITIONER/PLAINTIFF:

RESPONDENT/DEFENDANT:

OTHER PARENT: