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PARTY WITHOUT ATTORNEY OR ATTORNEY (name, state bar number, and address):

STATE BAR NO.:

FOR COURT USE ONLY

FL-676

STATE:

FAX NO.:

ZIP CODE:

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

NAME:

FIRM NAME:

STREET ADDRESS:

CITY:

TELEPHONE NO.:

E-MAIL ADDRESS:

ATTORNEY FOR (name):

STREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

PETITIONER:

RESPONDENT:

OTHER PARTY:

• Use this form if you disagree with the local child support agency about how much back support (arrears) is owed.

INSTRUCTIONS

• Complete items 4–6. For more information about completing this form, see Information Sheet: Request for Determination of Support

Arrears ( ).

• After you fill out the request and any attachments, take the originals plus three copies to the court clerk to file.

• After you file, copies of your court papers must be "served" on the local child support agency and the other party in the case, and

you must file a proof of service with the court. See for more information about serving the request.

• Make sure you go to the court hearing listed in item 1.

• For help completing this form, talk to the in your county.

NOTICE OF HEARING

1. A hearing on this application will be held as follows:

a. Date:

Time:

Dept:

Div:

Room:

b. The address of the court is

same as noted above

Other (specify):

2. WARNING to the person served with this request: The court may make the requested orders without you if you do not file a

Response to Governmental Notice of Motion or Order to Show Cause
INFO for more information about filing a response.

and appear at the hearing. See

3. The local child support agency is providing support enforcement services in this case.

4. a.

did

did not

request an administrative review of support received by the local child support agency.

A printout listing support payments received by the local child support agency

is not

attached.

I ask that the amount of past due support payments (arrears) be adjusted in this case (check all that apply).

I disagree with how much support the local child support agency says was paid. I am attaching my own payment history
with a monthly breakdown of how much was ordered and how much was paid.

Form Adopted for Mandatory Use
Judicial Council of California
FL-676 [Rev. January 1, 2022]

REQUEST FOR DETERMINATION OF SUPPORT ARREARS
(Governmental)

Page 1 of 2

Family Code, §§ 4007.5, 17526

REQUEST FOR DETERMINATION OF SUPPORT ARREARS

CASE NUMBER:

PETITIONER:

RESPONDENT:

OTHER PARTY:

5. b.

I could not pay child support because

CASE NUMBER:

FL-676

(1) After December 31, 2020, my child support order was entered or modified, and I was confined against my will for more

than 90 days in a row in jail, prison, juvenile detention, a mental health facility, or other institution (attach proof).

(a) Start date:

(b) End date:

(2)

I was not confined for
(a) domestic violence against the other parent or our child; or
(b)

failing to pay a child support order.

(3)

I had no money available to pay child support while I was confined.

The child support order entered on (date):
would stop

by operation of law (specify the reasons why and attach applicable proof):

was stopped (suspended) because

the order says it

Other (specify):

I have attached (check all that apply):

a Declaration of Payment History ( ).

a Payment History Attachment ( ).

a printout listing support payments received by the local child support agency.

Other (specify):

Date:

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

(TYPE OR PRINT NAME)

(SIGNATURE)

This case may be referred to a court commissioner for hearing. By law, court commissioners do not have the authority to issue final
orders and judgments in contested cases unless they are acting as temporary judges. The court commissioner in your case will act as
a temporary judge unless, before the hearing, you or any other party objects to the commissioner’s acting as a temporary judge. If you
or the other party objects, the court commissioner may still hear your case to make findings and a recommended order to a judge. If
you do not like the recommended order, you must object to it within 10 court days in writing (use Notice of Objection ( ));
otherwise, the recommended order will become a final order of the court. If you object to the recommended order, a judge will make a
temporary order and set a new hearing.

FL-676 [Rev. January 1, 2022]

REQUEST FOR DETERMINATION OF SUPPORT ARREARS
(Governmental)

Page 2 of 2

Request for Determination of Support Arrears (Governmental)

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the California state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from selfhelp.courts.ca.gov (2023-03)
Page(s): 2
Fields(s): 54
Average fields per page: 27
Reading Level: Grade 8
LIST Grouping(s): CO-00-00-00-00, CO-07-00-00-00.

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

f_l_page_p_header_info_name was FL-676[0].Page1[0].P1Header[0].AttyInfo[0].Name[0] (0.56 conf)
f_page_p_header_info_number was FL-676[0].Page1[0].P1Header[0].AttyInfo[0].BarNumber[0] (0.39 conf)
f_l_page_p_header_info_firm was FL-676[0].Page1[0].P1Header[0].AttyInfo[0].Firm[0] (0.41 conf)
f_page_p_header_info_address was FL-676[0].Page1[0].P1Header[0].AttyInfo[0].Address[0] (0.41 conf)
f_l_page_p_header_info_city__1 was FL-676[0].Page1[0].P1Header[0].AttyInfo[0].City[0] (0.41 conf)
f_page_p_header_info_state was FL-676[0].Page1[0].P1Header[0].AttyInfo[0].State[0] (0.41 conf)
f_page_p_header_info_zip_code was FL-676[0].Page1[0].P1Header[0].AttyInfo[0].ZipCode[0] (0.42 conf)
f_l_page_p_header_info_tel was FL-676[0].Page1[0].P1Header[0].AttyInfo[0].AttyTel[0] (0.42 conf)
f_l_page_p_header_info_fax was FL-676[0].Page1[0].P1Header[0].AttyInfo[0].Fax_ft[0] (0.44 conf)
f_page_p_header_info_email was FL-676[0].Page1[0].P1Header[0].AttyInfo[0].AttyEmail[0] (0.42 conf)
f_l_page_p_header_info_ft was FL-676[0].Page1[0].P1Header[0].AttyInfo[0].AttyFor_ft[0] (0.44 conf)
f_l_page_p_info_county was FL-676[0].Page1[0].P1Header[0].CourtInfo[0].CrtCounty_ft[0] (0.35 conf)
f_l_page_p_info_street was FL-676[0].Page1[0].P1Header[0].CourtInfo[0].Street_ft[0] (0.42 conf)
f_l_page_p_header_info was FL-676[0].Page1[0].P1Header[0].CourtInfo[0].MailingAdd_ft[0] (0.43 conf)
f_l_page_p_header_info_city__2 was FL-676[0].Page1[0].P1Header[0].CourtInfo[0].CityZip_ft[0] (0.44 conf)
f_l_page_p_info_branch was FL-676[0].Page1[0].P1Header[0].CourtInfo[0].Branch_ft[0] (0.42 conf)
f_page_p_title_party_name__1 was FL-676[0].Page1[0].P1Header[0].TitlePartyName[0].Party1[0] (0.37 conf)
f_page_p_title_party_name__2 was FL-676[0].Page1[0].P1Header[0].TitlePartyName[0].Party2[0] (0.37 conf)
f_page_p_title_party_name__3 was FL-676[0].Page1[0].P1Header[0].TitlePartyName[0].Party3[0] (0.37 conf)
f_l_page_p_header_case_number was FL-676[0].Page1[0].P1Header[0].CaseNumber[0].CaseNumber_ft[0] (0.41 conf)
f_l_page_list_date was FL-676[0].Page1[0].List1[0].LI1[0].Date[0] (0.37 conf)
f_l_page_list_time was FL-676[0].Page1[0].List1[0].LI1[0].Time[0] (0.37 conf)
f_l_page_list_dept was FL-676[0].Page1[0].List1[0].LI1[0].Dept[0] (0.37 conf)
f_l_page_list_div was FL-676[0].Page1[0].List1[0].LI1[0].Div[0] (0.37 conf)
f_l_page_list_room was FL-676[0].Page1[0].List1[0].LI1[0].Room[0] (0.37 conf)
f_l_page_list_c_b_choice__1 was FL-676[0].Page1[0].List1[0].LI2[0].CB1[0].CBChoice[0] (0.34 conf)
f_l_page_list_c_b_text__1 was FL-676[0].Page1[0].List1[0].LI2[0].CB2[0].TextField2[0] (0.36 conf)
f_l_page_list_c_b_choice__2 was FL-676[0].Page1[0].List1[0].LI2[0].CB2[0].CBChoice[0] (0.34 conf)
f_l_page_list_c_b__1 was FL-676[0].Page1[0].List4[0].LI1[0].CB1[0].DidORDidNot[0] (0.40 conf)
f_l_page_list_c_b__2 was FL-676[0].Page1[0].List4[0].LI1[0].CB2[0].DidORDidNot[1] (0.40 conf)
f_l_page_list_c_b__3 was FL-676[0].Page1[0].List4[0].LI2[0].CB3[0].IsORIsNot[0] (0.38 conf)
f_l_page_list_c_b__4 was FL-676[0].Page1[0].List4[0].LI2[0].CB4[0].IsORIsNot[1] (0.38 conf)
f_l_page_list_c_b_petitioner_cb__1 was FL-676[0].Page1[0].List5[0].LI1[0].CB5[0].petitioner_cb[0] (0.37 conf)
f_l_page_caption_party__1 was FL-676[0].Page2[0].ThreepartyPxCaption[0].Party1[0] (0.38 conf)
f_l_page_caption_party__2 was FL-676[0].Page2[0].ThreepartyPxCaption[0].Party2[0] (0.38 conf)
f_l_page_caption_party__3 was FL-676[0].Page2[0].ThreepartyPxCaption[0].Party3[0] (0.38 conf)
f_l_page_px_case_number was FL-676[0].Page2[0].ThreepartyPxCaption[0].CaseNumber_ft[0] (0.35 conf)
f_l_page_list_c_b_petitioner_cb__2 was FL-676[0].Page2[0].List5[0].LI1[0].CB1[0].petitioner_cb[0] (0.37 conf)
f_l_page_list_li_start_date was FL-676[0].Page2[0].List5[0].LI1[0].Li1\.1[0].Li1\.1\.1[0].StartDate[0] (0.38 conf)
f_l_page_list_li_end_date was FL-676[0].Page2[0].List5[0].LI1[0].Li1\.1[0].Li1\.1\.2[0].EndDate[0] (0.38 conf)
f_l_page_list_c_b_petitioner_cb__3 was FL-676[0].Page2[0].List5[0].LI2[0].CB1[0].petitioner_cb[0] (0.37 conf)
f_l_page_list_date_field was FL-676[0].Page2[0].List5[0].LI2[0].DateField1[0] (0.34 conf)
f_l_page_list_c_b_petitioner_cb__4 was FL-676[0].Page2[0].List5[0].LI2[0].CB2[0].petitioner_cb[1] (0.37 conf)
f_l_page_list_c_b_petitioner_cb__5 was FL-676[0].Page2[0].List5[0].LI2[0].CB3[0].petitioner_cb[2] (0.37 conf)
f_l_page_list_text_field__1 was FL-676[0].Page2[0].List5[0].LI2[0].TextField[0] (0.33 conf)
f_l_page_list_text_field__2 was FL-676[0].Page2[0].List5[0].LI3[0].TextField1[0] (0.33 conf)
f_page_list_c_b_check_box__1 was FL-676[0].Page2[0].List5[0].LI3[0].CB4[0].CheckBox61[0] (0.37 conf)
f_l_page_list_c_b_petitioner_cb__6 was FL-676[0].Page2[0].List6[0].LI1[0].CB1[0].petitioner_cb[0] (0.37 conf)
f_l_page_list_c_b_petitioner_cb__7 was FL-676[0].Page2[0].List6[0].LI2[0].CB2[0].petitioner_cb[0] (0.37 conf)
f_page_list_c_b_check_box__2 was FL-676[0].Page2[0].List6[0].LI3[0].CB3[0].CheckBox61[0] (0.37 conf)
f_page_list_c_b_check_box__3 was FL-676[0].Page2[0].List6[0].LI4[0].CB4[0].CheckBox62[0] (0.37 conf)
f_l_page_list_c_b_text__2 was FL-676[0].Page2[0].List6[0].LI4[0].CB4[0].TextField6[0] (0.36 conf)
f_l_page_signature_date was FL-676[0].Page2[0].Signature[0].Date[0] (0.35 conf)
f_l_page_signature_name was FL-676[0].Page2[0].Signature[0].Name[0] (0.35 conf)

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Request for Determination of Support Arrears (Governmental)

About This Form:

Identified Data Fields:

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02