Declaration For Default Or Uncontested Dissolution / Legal Separation Page 3
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3FL-170
CASE NUMBER:
PETITIONER:
RESPONDENT:
Parentage of the children of the petitioner and respondent born prior to their marriage or domestic partnership should be
9.
ordered as set forth in the proposed Judgment (form FL-180).
a.
A Voluntary Declaration of Paternity is attached.
b.
Parentage was previously established by the court in (county):
The case number is (specify):
Written agreement of the parties attached here or to the Judgment (form FL-180).
10.
Attorney fees should be ordered as set forth in the proposed Judgment (form FL-180)
facts in support in form FL-319
other (specify facts below):
11.
The judgment should be entered nunc pro tunc for the following reasons (specify):
12.
The petitioner
respondent
requests restoration of his or her former name as set forth in the proposed Judgment
(form FL-180).
13.
There are irreconcilable differences that 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
If this is a dissolution of marriage or of a domestic partnership created in another state, the petitioner and/or the respondent
15.
have been residents 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.
I ask that the court grant the request for a judgment for 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.
17.
This declaration is for the termination of marital or domestic partner status only. I ask the court to reserve jurisdiction
over all issues whose determination is not requested in this declaration.
THIS STATEMENT APPLIES ONLY TO LEGAL SEPARATIONS
18.
I ask that the court grant the request for 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.
I 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.
Date:
(TYPE OR PRINT NAME)
(SIGNATURE OF DECLARANT)
Page 3 of 3
FL-170 [Rev. July 1, 2012]
DECLARATION FOR DEFAULT OR UNCONTESTED
DISSOLUTION OR LEGAL SEPARATION
(Family Law)
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