PETITIONER / PLAINTIFF:

RESPONDENT / DEFENDANT:

OTHER PARENT:

CASE NUMBER:

FL-684

I REQUEST THE FOLLOWING ORDERS FOR: 

Name of child

Date of birth

Name of child

Date of birth

(THIS IS A REQUEST, NOT AN ORDER)

1.

2.

3.

4.

5.

PARENTAGE.  If not previously established, a judgment that you are the parent of the children named above.

CHILD SUPPORT.  Monthly child support based on the state guideline. (An Income Withholding for Support (FL-195/OMB No. 
0970-0154) will be issued.)

a.

This is a request for a change to an existing order 
(1)   filed on (date if known):
(2)   ordering (specify):
b.  Child support to commence 

(1)  on the date this request was mailed or given to you.
(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.

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.

FEES AND COSTS

Fees: $

Costs: $

PROPERTY RESTRAINT

Petitioner/plaintiff

Respondent/defendant

Other parent

be restrained from transferring, encumbering, hypothecating, concealing, or in any way disposing of the following property
(specify):

Form Adopted for Mandatory Use 
Judicial Council of California 
FL-684 [Rev. January 1, 2010]

REQUEST FOR ORDER AND SUPPORTING DECLARATION 
(Governmental)

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Family Code §§ 215, 3751, 3761, 
3900-3901, 4001-4062, 4007, 4009, 4014,
4050-4076, 4200-4204, 7551,17304, 17400,
17402,17404, 17406,17422 
www.courtinfo.ca.gov

PETITIONER / PLAINTIFF:

RESPONDENT / DEFENDANT:

OTHER PARENT:

6.

OTHER (specify):

CASE NUMBER:

FL-684

7.

FACTS IN SUPPORT of this request are: 

contained in an attached declaration.

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)

FL-684 [Rev. January 1, 2010]

REQUEST FOR ORDER AND SUPPORTING DECLARATION 
(Governmental)

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