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FL-195: FL 195 Form | CA Small Claims

FL-195GeneralFillable PDF

FL 195 Form

1

list

Document Date

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Field 3

Field 4

Field 5

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Field 7

Field 8

Field 9

Button

Issuing State Tribe Territory Name

Remittance Identifier

Issuing Jurisdiction Name

Order Identifier A

Private Individual Entity Name

Case Identifier A

Employee Name A

Employer Name A

Employee Ssn

Employer Address

Employee Dob

Employer Address

Obligee Name

Employer Address

Text Field

Child1 Birth Date

Child1 Name

Child2 Name

Child2 Birth Date

Child3 Name

Child3 Birth Date

Child4 Name

Child4 Birth Date

Child5 Name

Child5 Birth Date

Child6 Name

Child6 Birth Date

Issuing Tribunal Name

Support Current Child Frequency Code$

Support Current Child Amount$

Support Past Due Child Amount$

Support Past Due Child Frequency Code

Yes No

Yes No

Support Current Medical Amount$

Support Current Medical Frequency Code$

Support Past Due Medical Amount$

Support Past Due Medical Frequency Code

Support Current Spousal Amount$

Support Current Spousal Frequency Code$

Support Past Due Spousal Amount$

Support Past Due Spousal Frequency Code

Obligation Other Amount$

Obligation Other Frequency Code

Obligation Other Description Text

Obligation Total Amount$

Obligation Total Frequency Code

Income Withholding Semimonthly Amount$

Income Withholding Deduction Weekly Amount$

Income Withholding Monthly Amount$

Income Withholding Deduction Bi Weekly Amount$

Lump Sum Payment Amount$

Document Tracking Number

Text Field

Text Field

Income Withholding Start Date

Send Payment Within Days Number$

Income Withholding Ccpa Rate$

Employment Place Name

Button

Button

Button

Button

Button

Employment Place Name A

Button

Return Send Ind

Goverment Official Signature

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Government Official Name

Issuing Official Title Text

Dateof Signiture

Send Employee Copy Indicator

Button

Penalty Liability Info Text

Anti Discrimination Provisions Text

Specific Payee Withholding Limits Text

Button

Employment Indicator

Employment Indicator

Termination Date

Last Know Phone

Last Know Address

Last Know Address

Date Final Paymentto Sdu

Final Paymentto Sdu Amount$

New Employer Name

New Employer Address

New Employer Address

Employer State Contact Name

Textfield

Textfield

Textfield

Employer State Contact Address

Employer State Contact Address

Employee State Contact Name

Textfield

Textfield

Textfield

2

text_field

Text Field

Text Field

Text Field

3

employer_name_a

Employer Name A

Employer Name A

Employer Name A

4

employee_name_a

Employee Name A

Employee Name A

Employee Name A

5

employee_ssn

Employee Ssn

Employee Ssn

Employee Ssn

6

case_identifier_a

Case Identifier A

Case Identifier A

Case Identifier A

7

order_identifier_a

Order Identifier A

Order Identifier A

Order Identifier A

8

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