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Here is the text we could read:

PARTY WITHOUT ATTORNEY OR ATTORNEY

STATE BAR NUMBER:

FOR COURT USE ONLY

FL-170

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:

DECLARATION FOR DEFAULT OR UNCONTESTED

DISSOLUTION   

LEGAL SEPARATION

CASE NUMBER:

(NOTE: Items 1 through 12 apply to both dissolution and legal separation proceedings.)
1.

I declare that if I appeared in court and were sworn, I would testify to the truth of the facts in this declaration.

I agree that my case will be proven by this declaration and that I will not appear before the court unless I am ordered by the court to 
do so.

All the information in the

amended

Petition

Response

is true and correct.

2.

3.

4.

Type of case (check a, b, or c):
a.

Default without agreement

No response has been filed and there is no written agreement or stipulated judgment between the parties; 

The default of the respondent was entered or is being requested, and I am not seeking any relief not requested in the 
petition; and       

The following statement is true (check one):
(A)
(B)

There are no assets or debts to be disposed of by the court. 
The community and quasi-community assets and debts are listed on the completed current Property 
Declaration (form FL-160), which includes an estimate of the value of the assets and debts that I propose to 
be distributed to each party. The division in the proposed Judgment (form FL-180) is a fair and equal division 
of the property and debts, or if there is a negative estate, the debts are assigned fairly and equitably.

Default with agreement
No response has been filed and the parties have agreed that the matter may proceed as a default matter without notice; 
and  
The parties have entered into a written agreement regarding their property and their marriage or domestic partnership 
rights, including support, the original of which is being or has been submitted to the court. I request that the court approve 
the agreement.      

c.

Uncontested

Both parties have appeared in the case; and   
The parties have entered into a written agreement regarding their property and their marriage or domestic partnership 
rights, including support, the original of which is being or has been submitted to the court. I request that the court approve 
the agreement.      

5.

Declaration of disclosure (check a, b, c, or d):
a.

Both the parties have filed, or are filing concurrently, a Declaration Regarding Service of Declaration of Disclosure (form 
FL-141) and an Income and Expense Declaration (form FL-150).
This matter is proceeding by default. I am the petitioner in this action and have filed a proof of service of the preliminary 
Declaration of Disclosure (form FL-140) with the court. I hereby waive receipt of the final Declaration of Disclosure (form 
FL-140) from the respondent.
This matter is proceeding by default. I am the petitioner in this action, and service of the summons on respondent was 
done by publication or posting under court order. Service of the preliminary Declaration of Disclosure (form FL-140) is not 
required. I hereby waive receipt of the final Declaration of Disclosure (form FL-140) from the respondent.

Form Approved for Mandatory Use 
Judicial Council of California 
FL-170 [Rev. January 17, 2020]

DECLARATION FOR DEFAULT OR UNCONTESTED 
DISSOLUTION OR LEGAL SEPARATION  
(Family Law)

Page 1 of 3

Family Code, § 2336 
www.courts.ca.gov

(1)

(2)

(3)

(1)

(2)

(1)
(2)

b.

b.

c.

d.

a.

b.

c.

c.
d.

e.

f.

PETITIONER:

RESPONDENT:

CASE NUMBER:

FL-170

This matter is proceeding as an uncontested action. Service of the final Declaration of Disclosure (form FL-140) is 
mutually waived by both parties. A waiver provision executed by both parties under penalty of perjury is contained on the 
Stipulation and Waiver of Final Declaration of Disclosure (form FL-144), in the settlement agreement or proposed 
judgment, or in another, separate stipulation.

6.

Child custody and visitation (parenting time) should be ordered as set forth in the proposed Judgment (form FL-180).

The information in Declaration Under Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) (form FL-105)     

has

has not

changed since it was last filed with the court. (If changed, attach updated form.)

There is an existing court order for custody/parenting time in another case in 
The case number is (specify):
The current custody and visitation (parenting time) previously ordered in this case, or the current schedule is (specify):  

(county):  

Contained on Attachment 6c.

d.

The facts that support the requested judgment are (In a default case, state your reasons below):

Contained on Attachment 6d.

7.

Child support should be ordered as set forth in the proposed Judgment (form FL-180).

a.

If there are minor children, check and complete item (1) if applicable and item (2) or (3): 
(1)

(2)

(3)

Child support is being enforced in another case in 
The case number is (specify):
The information in the child support calculation attached to the proposed judgment is correct based on my personal 
knowledge.

(county):

I request that this order be based on the
support of my estimate of earning ability are (specify): 

Petitioner's

Respondent's

earning ability. The facts in  

b.

Complete items (1) and (2) regarding public assistance.

Contained on Attachment 7a(3).

(1)

(2)

am receiving

I
listed in the proposed order. 
To the best of my knowledge, the other party 

am not receiving

intend to apply for

public assistance for the child or children

Petitioner

Respondent

is presently receiving public assistance, and all support should be made payable

to the local child support agency at the address set forth in the proposed judgment. A representative of the local child 
support agency has signed the proposed judgment.

is

is not

receiving public assistance.

8.

Spousal, Partner, and Family Support (If a support order or attomey fees are requested, submit a completed Income and 
Expense Declaration (form FL-150) unless a current form is on file. Include your best estimate of the other party’s income. 
Check at least one of the following.)
a.
b.

I knowingly give up forever any right to receive spousal or partner support.
I ask the court to reserve jurisdiction to award spousal or partner support in the future to: 

Petitioner

Respondent

I ask the court to terminate forever spousal or partner support for:
Spousal support or domestic partner support should be ordered as set forth in the proposed Judgment (form FL-180) 
based on the factors described in:            

Respondent

Petitioner

Spousal or Partner Support Declaration Attachment (form FL-157)
written agreement
attached declaration (Attachment 8d)

Family support should be ordered as set forth in the proposed Judgment (form FL-180).

Other (specify):

FL-170 [Rev. January 17, 2020]

Page 2 of 3

DECLARATION FOR DEFAULT OR UNCONTESTED 
DISSOLUTION OR LEGAL SEPARATION  
(Family Law)

PETITIONER:

RESPONDENT:

CASE NUMBER:

FL-170

9.

Parentage of the children of the petitioner and respondent born prior to their marriage or domestic partnership should be 
ordered as set forth in the proposed Judgment (form FL-180). 

a.
b.

A voluntary declaration of parentage or paternity is attached.
Parentage was previously established by the court in 
The case number is (specify):
The written agreement of the parties regarding parentage is attached here (Attachment 9b) or to the proposed Judgment 
(form FL-180).

(county):

10.

Attorney fees should be ordered as set forth in the proposed Judgment (form FL-180). 

The facts in support of this request are on Request for Attorney's Fees and Costs Attachment (form FL-319).
Other (specify facts below):

Petitioner

Respondent

 requests restoration of the former name as set forth in the proposed Judgment (form FL-180)

(proceedings for dissolution or nullity of marriage only).

13.

Irreconcilable differences have led to the irremediable breakdown of the marriage or domestic partnership, and there is no 
possibility of saving the marriage or domestic partnership through counseling or other means.

14.

This declaration may be reviewed by a commissioner sitting as a temporary judge, who may determine whether to grant this 
request or require my appearance under Family Code section 2336.

STATEMENTS IN THIS BOX APPLY ONLY TO DISSOLUTIONS

15.

If this is a dissolution of a marriage or domestic partnership created in another state, the petitioner or the respondent has 
been a resident of this county for at least three months and of the state of California for at least six months continuously and 
immediately preceding the date of the filing of the petition for dissolution of marriage or domestic partnership.

16.

17.

I ask that the court grant the request for a judgment of dissolution of marriage or domestic partnership based on irreconcilable 
differences and that the court make the orders set forth in the proposed Judgment (form FL-180) submitted with this declaration.
Status only judgment: This declaration is only for the termination of marital or domestic partner status. I ask the court to 
reserve jurisdiction over all other issues not requested in this declaration for later determination.

18.

THIS STATEMENT APPLIES ONLY TO LEGAL SEPARATIONS
I ask that the court grant the request of a judgment for legal separation based on irreconcilable differences and that the court 
make the orders set forth in the proposed Judgment (form FL-180) submitted with this declaration. 

 understand that a judgment of legal separation does not terminate a marriage or domestic partnership, and that I am 
still married or a partner in a domestic partnership.

19.

Other (specify):

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 OF DECLARANT)

FL-170 [Rev. January 17, 2020]

Page 3 of 3

DECLARATION FOR DEFAULT OR UNCONTESTED 
DISSOLUTION OR LEGAL SEPARATION  
(Family Law)

11.

12.

  I

Date:

The judgment should be entered nunc pro tunc for the following reasons (specify):

Declaration for Default or Uncontested Dissolution or Legal Separation (Family Law)

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): 3
Fields(s): 102
Average fields per page: 34
Reading Level: Grade 9
LIST Grouping(s): FA-00-00-00-00, FA-06-00-00-00, 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_check_box__1 was FL-170[0].Page1[0].CheckBox1[0] (0.56 conf)
f_l_page_check_box__2 was FL-170[0].Page1[0].CheckBox1[1] (0.41 conf)
f_l_page_check_box__3 was FL-170[0].Page1[0].CheckBox1[2] (0.41 conf)
f_l_page_check_box__4 was FL-170[0].Page1[0].CheckBox1[3] (0.41 conf)
f_l_page_check_box__5 was FL-170[0].Page1[0].CheckBox1[4] (0.41 conf)
f_l_page_check_box__6 was FL-170[0].Page1[0].CheckBox1[5] (0.41 conf)
f_l_page_check_box__7 was FL-170[0].Page1[0].CheckBox1[6] (0.41 conf)
f_l_page_check_box__8 was FL-170[0].Page1[0].CheckBox1[7] (0.41 conf)
f_l_page_p_form_title__1 was FL-170[0].Page1[0].CaptionP1_sf[0].FormTitle[0].Amended_cb[0] (0.39 conf)
f_l_page_p_form_title__2 was FL-170[0].Page1[0].CaptionP1_sf[0].FormTitle[0].DissolutionOf_cb[0] (0.42 conf)
f_l_page_caption_p_sf_info__1 was FL-170[0].Page1[0].CaptionP1_sf[0].AttyInfo[0].AttyFor_ft[0] (0.38 conf)
f_l_page_p_sf_info_email was FL-170[0].Page1[0].CaptionP1_sf[0].AttyInfo[0].Email_ft[0] (0.44 conf)
f_l_page_caption_p_info_ft was FL-170[0].Page1[0].CaptionP1_sf[0].AttyInfo[0].Fax_ft[0] (0.42 conf)
f_l_page_p_sf_info_phone was FL-170[0].Page1[0].CaptionP1_sf[0].AttyInfo[0].Phone_ft[0] (0.38 conf)
f_l_page_p_sf_info_ft__1 was FL-170[0].Page1[0].CaptionP1_sf[0].AttyInfo[0].AttyZip_ft[0] (0.44 conf)
f_l_page_p_info_state_ft was FL-170[0].Page1[0].CaptionP1_sf[0].AttyInfo[0].AttyState_ft[0] (0.44 conf)
f_l_page_caption_p_info_city was FL-170[0].Page1[0].CaptionP1_sf[0].AttyInfo[0].AttyCity_ft[0] (0.40 conf)
f_l_page_p_info_street__1 was FL-170[0].Page1[0].CaptionP1_sf[0].AttyInfo[0].AttyStreet_ft[0] (0.38 conf)
f_l_page_p_sf_info_ft__2 was FL-170[0].Page1[0].CaptionP1_sf[0].AttyInfo[0].AttyFirm_ft[0] (0.41 conf)
f_l_page_caption_p_info_name was FL-170[0].Page1[0].CaptionP1_sf[0].AttyInfo[0].AttyName_ft[0] (0.38 conf)
f_l_page_caption_p_sf_info__2 was FL-170[0].Page1[0].CaptionP1_sf[0].AttyInfo[0].BarNo_ft[0] (0.39 conf)
f_l_page_p_sf_county was FL-170[0].Page1[0].CaptionP1_sf[0].CourtInfo[0].CrtCounty_ft[0] (0.41 conf)
f_l_page_p_info_branch was FL-170[0].Page1[0].CaptionP1_sf[0].CourtInfo[0].Branch_ft[0] (0.37 conf)
f_l_page_p_info_city_ft was FL-170[0].Page1[0].CaptionP1_sf[0].CourtInfo[0].CityZip_ft[0] (0.38 conf)
f_l_page_p_info_street__2 was FL-170[0].Page1[0].CaptionP1_sf[0].CourtInfo[0].Street_ft[0] (0.39 conf)
f_l_page_p_info_add was FL-170[0].Page1[0].CaptionP1_sf[0].CourtInfo[0].MailingAdd_ft[0] (0.39 conf)
f_page_p_title_party_name__1 was FL-170[0].Page1[0].CaptionP1_sf[0].TitlePartyName[0].Party2_ft[0] (0.36 conf)
f_page_p_title_party_name__2 was FL-170[0].Page1[0].CaptionP1_sf[0].TitlePartyName[0].Party1_ft[0] (0.36 conf)
f_l_page_p_sf_case_number was FL-170[0].Page1[0].CaptionP1_sf[0].CaseNumber[0].CaseNumber_ft[0] (0.39 conf)
f_l_page_r_b_choices__1 was FL-170[0].Page1[0].RB2Choices[0] (0.33 conf)
f_l_page_r_b_choices__2 was FL-170[0].Page1[0].RB2Choices[1] (0.33 conf)
f_l_page_r_b_choices__3 was FL-170[0].Page1[0].RB2Choices[2] (0.33 conf)
f_l_page_check_box__9 was FL-170[0].Page2[0].CheckBox1[0] (0.41 conf)
f_l_page_check_box__10 was FL-170[0].Page2[0].CheckBox1[1] (0.41 conf)
f_l_page_r_b_choices__4 was FL-170[0].Page2[0].RB2Choices[0] (0.33 conf)
f_l_page_r_b_choices__5 was FL-170[0].Page2[0].RB2Choices[1] (0.33 conf)
f_l_page_r_b_choices__6 was FL-170[0].Page2[0].RB2Choices[2] (0.33 conf)
l_page_caption_title_party_name__1 was FL-170[0].Page2[0].pxCaption[0].TitlePartyName[0].Party2_ft[0] (0.35 conf)
l_page_caption_title_party_name__2 was FL-170[0].Page2[0].pxCaption[0].TitlePartyName[0].Party1_ft[0] (0.35 conf)
f_l_page_px_case_number was FL-170[0].Page2[0].pxCaption[0].CaseNumber[0].CaseNumber_ft[0] (0.40 conf)
f_l_page_r_b_choices__7 was FL-170[0].Page2[0].RB2Choices[3] (0.33 conf)
f_l_page_r_b_choices__8 was FL-170[0].Page2[0].RB2Choices[4] (0.33 conf)
f_l_page__1 was FL-170[0].Page2[0].T313[0] (0.37 conf)
f_l_page_attach_cb__1 was FL-170[0].Page2[0].attach6d_cb[0] (0.36 conf)
f_l_page_attach_cb__2 was FL-170[0].Page2[0].Attach_cb[0] (0.42 conf)
f_l_page_r_b_choices__9 was FL-170[0].Page2[0].RB2Choices[5] (0.33 conf)
f_l_page_check_box__11 was FL-170[0].Page2[0].CheckBox1[2] (0.41 conf)
f_l_page__2 was FL-170[0].Page2[0].T303[0] (0.37 conf)
f_l_page__3 was FL-170[0].Page2[0].T313[1] (0.37 conf)
f_l_page__4 was FL-170[0].Page2[0].T313[2] (0.37 conf)
f_l_page_check_box__12 was FL-170[0].Page2[0].CheckBox1[3] (0.41 conf)
f_l_page_check_box__13 was FL-170[0].Page2[0].CheckBox1[4] (0.41 conf)
f_l_page_check_box__14 was FL-170[0].Page2[0].CheckBox1[5] (0.41 conf)
f_l_page__5 was FL-170[0].Page2[0].T316[0] (0.37 conf)
f_l_page__6 was FL-170[0].Page2[0].T317[0] (0.37 conf)
f_l_page_r_b_choices__10 was FL-170[0].Page2[0].RB2Choices[6] (0.33 conf)
f_l_page_r_b_choices__11 was FL-170[0].Page2[0].RB2Choices[7] (0.33 conf)
f_l_page__7 was FL-170[0].Page2[0].T313[3] (0.37 conf)
f_l_page_attach_cb__3 was FL-170[0].Page2[0].attach7a3_cb[0] (0.36 conf)
f_l_page_r_b_choices__12 was FL-170[0].Page2[0].RB2Choices[8] (0.33 conf)
f_l_page_r_b_choices__13 was FL-170[0].Page2[0].RB2Choices[9] (0.33 conf)
f_l_page_r_b_choices__14 was FL-170[0].Page2[0].RB2Choices[10] (0.33 conf)
f_l_page_r_b_choices__15 was FL-170[0].Page2[0].RB2Choices[11] (0.33 conf)
f_l_page_r_b_choices__16 was FL-170[0].Page2[0].RB2Choices[12] (0.33 conf)
f_l_page_r_b_choices__17 was FL-170[0].Page2[0].RB2Choices[13] (0.33 conf)
f_l_page_r_b_choices__18 was FL-170[0].Page2[0].RB2Choices[14] (0.33 conf)
f_l_page_r_b_choices__19 was FL-170[0].Page2[0].RB2Choices[15] (0.33 conf)
f_l_page_r_b_choices__20 was FL-170[0].Page2[0].RB2Choices[16] (0.33 conf)
f_l_page_r_b_choices__21 was FL-170[0].Page2[0].RB2Choices[17] (0.33 conf)
f_l_page_r_b_choices__22 was FL-170[0].Page2[0].RB2Choices[18] (0.33 conf)
f_l_page_r_b_choices__23 was FL-170[0].Page2[0].RB2Choices[19] (0.33 conf)
f_l_page_r_b_choices__24 was FL-170[0].Page2[0].RB2Choices[20] (0.33 conf)
f_l_page_r_b_choices__25 was FL-170[0].Page2[0].RB2Choices[21] (0.33 conf)
f_l_page_r_b_choices__26 was FL-170[0].Page2[0].RB2Choices[22] (0.33 conf)
f_l_page_r_b_choices__27 was FL-170[0].Page2[0].RB2Choices[23] (0.33 conf)
f_l_page_r_b_choices__28 was FL-170[0].Page2[0].RB2Choices[24] (0.33 conf)
f_l_page_r_b_choices__29 was FL-170[0].Page2[0].RB2Choices[25] (0.33 conf)
f_l_page_r_b_choices__30 was FL-170[0].Page2[0].RB2Choices[26] (0.33 conf)
f_l_page_r_b_choices__31 was FL-170[0].Page2[0].RB2Choices[27] (0.33 conf)
f_l_page_fill_text was FL-170[0].Page2[0].FillText109[0] (0.42 conf)
f_l_subform_r_b_choices__1 was FL-170[0].#subform[2].RB2Choices[0] (0.38 conf)
f_l_subform_fill_text__1 was FL-170[0].#subform[2].FillText1140[0] (0.40 conf)
f_l_subform_px_caption_title_party_name_ft__1 was FL-170[0].#subform[2].pxCaption[0].TitlePartyName[0].Party2_ft[0] (0.30 conf)
f_l_subform_px_caption_title_party_name_ft__2 was FL-170[0].#subform[2].pxCaption[0].TitlePartyName[0].Party1_ft[0] (0.30 conf)
f_l_subform_px_caption_number was FL-170[0].#subform[2].pxCaption[0].CaseNumber[0].CaseNumber_ft[0] (0.37 conf)
f_l_subform_fill_text__2 was FL-170[0].#subform[2].FillText56[0] (0.40 conf)
f_l_subform_check_box was FL-170[0].#subform[2].CheckBox1[0] (0.34 conf)
f_l_subform_r_b_choices__2 was FL-170[0].#subform[2].RB2Choices[1] (0.38 conf)
f_l_subform_r_b_choices__3 was FL-170[0].#subform[2].RB2Choices[2] (0.38 conf)
f_l_subform_r_b_choices__4 was FL-170[0].#subform[2].RB2Choices[3] (0.38 conf)
f_l_subform_fill_text__3 was FL-170[0].#subform[2].FillText109[0] (0.40 conf)
f_l_subform_r_b_choices__5 was FL-170[0].#subform[2].RB2Choices[4] (0.38 conf)
f_l_subform__1 was FL-170[0].#subform[2].T187[0] (0.36 conf)
f_l_subform_r_b_choices__6 was FL-170[0].#subform[2].RB2Choices[5] (0.38 conf)
f_l_subform_r_b_choices__7 was FL-170[0].#subform[2].RB2Choices[6] (0.38 conf)
f_l_subform_r_b_choices__8 was FL-170[0].#subform[2].RB2Choices[7] (0.38 conf)
f_l_subform__2 was FL-170[0].#subform[2].T317[0] (0.36 conf)
f_l_subform_r_b_choices__9 was FL-170[0].#subform[2].RB2Choices[8] (0.38 conf)
f_l_subform_r_b_choices__10 was FL-170[0].#subform[2].RB2Choices[9] (0.38 conf)
f_l_subform_fill_text__4 was FL-170[0].#subform[2].FillText109[1] (0.40 conf)
f_l_subform_fill_text__5 was FL-170[0].#subform[2].FillText109[2] (0.40 conf)
f_l_subform_r_b_choices__11 was FL-170[0].#subform[2].RB2Choices[10] (0.38 conf)

We've done our best to group similar variables togther to avoid overwhelming the user.

Suggested Screen 0:

f_l_page_check_box__1
f_l_page_check_box__2
f_l_page_check_box__3
f_l_page_check_box__4
f_l_page_check_box__5
f_l_page_check_box__6
f_l_page_check_box__7
f_l_page_check_box__8
f_l_page_p_form_title__1
f_l_page_p_form_title__2
f_l_page_caption_p_sf_info__1
f_l_page_p_sf_info_email
f_l_page_caption_p_info_ft
f_l_page_p_sf_info_phone
f_l_page_p_sf_info_ft__1
f_l_page_p_info_state_ft
f_l_page_caption_p_info_city
f_l_page_p_info_street__1
f_l_page_p_sf_info_ft__2
f_l_page_caption_p_info_name
f_l_page_caption_p_sf_info__2
f_l_page_p_sf_county
f_l_page_p_info_branch
f_l_page_p_info_city_ft
f_l_page_p_info_street__2
f_l_page_p_info_add
f_page_p_title_party_name__1
f_page_p_title_party_name__2
f_l_page_p_sf_case_number
f_l_page_r_b_choices__1
f_l_page_r_b_choices__2
f_l_page_r_b_choices__3
f_l_page_check_box__9
f_l_page_check_box__10
f_l_page_r_b_choices__4
f_l_page_r_b_choices__5
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