California Form FL-695 is the Notice of Rights and Responsibilities — Health-Care Costs and Reimbursement Procedures attachment that a parent files alongside a child support order to put the other parent on notice of how uninsured medical costs will be split, claimed, and reimbursed under California law. The form is published by the Judicial Council of California and is anchored to the most recent revision dated January 1, 2012, which is still the active version courts accept statewide.
Filing FL-695 wrong, late, or not at all can cost a parent thousands of dollars in unreimbursed medical bills and can derail a contempt action when the other parent refuses to pay their share. According to the California Department of Child Support Services, uninsured health-care costs are one of the top three sources of post-judgment family law disputes, with the state processing more than 1.1 million open child support cases each year.
Here is what you will learn in this guide:
- 📄 What FL-695 actually does and which California Family Code sections force you to use it
- 🧾 The exact documents, numbers, and dates to gather before opening the form
- ✍️ A line-by-line walkthrough of every box, signature line, and attachment on FL-695
- 👨👩👧 Three full filled-out examples using realistic California families
- ⚖️ How to file, serve, and enforce the form across every California county and channel
What Form FL-695 Is and Who Must File It
California Form FL-695 is a mandatory Judicial Council attachment that explains how parents must handle uninsured health-care costs for a child after a support order is entered. It is required by California Family Code section 4063 and is automatically attached to every child support order the court issues, whether the case is a dissolution, paternity, domestic partnership, or Department of Child Support Services (DCSS) Title IV-D matter.
The form spells out the 30-day rule: the parent who pays a medical bill must give the other parent written proof of the cost within a reasonable time, and the receiving parent must reimburse their share within 30 days. It also tells parents how to use insurance, how to pick in-network providers, and what happens if a parent refuses to cooperate. Because it is a notice form, FL-695 itself is not signed by the parents — it is signed by the judicial officer when the support order is signed, and then served on both parents along with the order.
Anyone with a California child support order must receive a copy of FL-695. That includes custodial parents, non-custodial parents, registered domestic partners with shared children, guardians collecting support on a child’s behalf, and any third party (like a grandparent caregiver) who is part of the support order. Self-represented filers, family law attorneys, paralegals working under attorney supervision, and DCSS caseworkers all interact with this form. The reading level on the official PDF is dense legalese, which is why so many parents miss key deadlines hidden in the text — and why a plain-English walkthrough matters.
The agency that ultimately enforces FL-695 is the California Superior Court in the county where the support order was entered, with parallel enforcement available through the local child support agency under Title IV-D of the federal Social Security Act. The federal Consumer Credit Protection Act interacts with FL-695 only when uninsured medical costs are added to a wage assignment, capping total withholding at 50–65% of disposable earnings.
Before You Start: Documents and Information You Need
FL-695 is short, but it sits on top of a stack of paperwork that must be accurate before you submit it with a proposed support order. Gathering the right documents up front prevents the clerk from rejecting your filing and prevents the other parent from challenging your reimbursement requests later. Read through the California Courts self-help guide on child support before you start so the field-level instructions below make sense in context.
Here is the pre-filing checklist with at least eight items every filer should have ready:
- The full case caption, including the petitioner’s name, respondent’s name, and case number — without this the clerk will not file the form.
- The current child support order or proposed FL-342 Child Support Information and Order Attachment — FL-695 is meaningless without an underlying order.
- Each child’s full legal name and date of birth — needed to match the support order and the health insurance policy.
- The health insurance policy number, group number, and carrier name for each parent’s available coverage — required by Family Code section 3751.
- A list of recent uninsured medical, dental, vision, and mental health bills you expect to share — not filed with FL-695 but needed to set up your record-keeping.
- The percentage allocation of uninsured costs from the support order, usually 50/50 unless the court ordered otherwise — this drives every reimbursement.
- The mailing address and email of the other parent for service of medical bills — wrong contact info voids your reimbursement demand.
- A working copy of Form FL-192 Notice of Rights and Responsibilities, which is the longer companion notice that often accompanies FL-695.
- Proof of payment for any medical bills you have already paid (canceled checks, EOBs, credit card statements) — needed if you ever file a contempt or enforcement motion.
- Your government-issued photo ID and a self-addressed stamped envelope if you plan to file by mail and want a conformed copy back.
If even one of these items is missing, the safest move is to pause, gather it, and then file. A rejected filing can push your support order back by weeks, and during that gap you are paying medical bills with no enforceable right to reimbursement.
Where to Get the Form and How to Access It
The only authoritative version of FL-695 is the official Judicial Council PDF hosted on courts.ca.gov. Do not download the form from third-party sites, attorney blogs, or document mills, because outdated revisions are still floating around the internet and clerks will reject anything that does not match the current Judicial Council layout. The current revision date January 1, 2012 is printed in the lower-left corner of page one, and you should confirm that date before you open the file.
You can also pick up a paper copy at the family law clerk’s window in any California superior court, including high-volume courthouses like the Stanley Mosk Courthouse in Los Angeles, the San Francisco Civic Center Courthouse, and the San Diego Central Courthouse. County self-help centers — sometimes called Family Law Facilitator’s Offices — also stock the form for free and will help you fill it out, as described on the California Courts Family Law Facilitator page.
If you are filing electronically, most California counties now use either Odyssey eFileCA or One Legal as the e-filing portal. The form must be uploaded as a flattened PDF, meaning the fillable fields are locked so the text does not shift on the clerk’s screen. Open the PDF in Adobe Acrobat Reader, fill it in, then choose Print to PDF to flatten before uploading. Filers using DCSS services will not need to download FL-695 themselves — the local child support agency attaches it automatically to every order.
Step-by-Step: How to Fill Out Form FL-695 Line by Line
FL-695 is a single-sided form with a caption block, a body of statutory notices, and a judicial officer’s signature line. Even though parents do not sign the form themselves, every field still has to be filled in correctly because the form is served on both parents and any error becomes part of the permanent court record. Work through the fields in the exact order they appear on the Judicial Council PDF, and italicize sample entries in your own notes so you can tell instructions apart from data.
Field 1: Attorney or Party Without Attorney (Top-Left Caption Box)
This box asks for the name, State Bar number, and address of the attorney filing the form, or the name and address of a self-represented party. Type the information in the same format used on every other Judicial Council form so the clerk can match filings across the case.
To answer it, write the filer’s full legal name on the first line, the firm name on the second line if there is one, the street address on the third line, and the city, state, and ZIP on the fourth line. Add the telephone number, fax, and email in the labeled subfields. Self-represented filers leave the State Bar number blank and write In Pro Per on the bar number line.
For example, Maria Lopez, 1428 Sunset Boulevard, Los Angeles, CA 90026, (213) 555-0142, maria.lopez@email.com, In Pro Per fills the box completely for a pro se petitioner. A nuance comes up when the filer has a confidential address under the Safe at Home program — in that case use the Safe at Home substitute address, never the home address.
A common mistake on this field is using a P.O. Box without also listing a physical address when local rules require both, which causes the clerk to reject the filing for service-of-process reasons. The misconception many parents carry is that this box is optional because FL-695 is a notice; it is not optional, and a blank caption is the single most common reason FL-695 is bounced back at the window.
Field 2: Superior Court of California, County Of (Court Name Block)
This block identifies the specific superior court where the case is pending. The clerk uses it to route the form to the right courtroom and to confirm venue under Family Code section 200.
Write the county name on the first line in all caps, then the street address of the courthouse, the mailing address if different, the city and ZIP, and the branch name. Use the exact address listed on the Find My Court directory for that county.
For example, Marcus Johnson filing in Sacramento writes SACRAMENTO, then 3341 Power Inn Road, then Sacramento, CA 95826, and William R. Ridgeway Family Relations Courthouse in the branch line. The nuance here is that some counties have multiple family law branches — Los Angeles alone has more than ten — so picking the wrong branch routes the form to a courtroom that has no authority over your case.
A common mistake is copying the address from the county clerk’s website instead of the court’s branch page, because the clerk’s office and the court are sometimes in different buildings. The misconception is that any courthouse in the county will do; venue is field-specific in family law, and a wrong branch entry can delay your support order by 30 days or more.
Field 3: Petitioner / Respondent / Other Parent / Other Parties (Party Block)
This block lists the people on the case caption. The names must match the original Petition exactly, including middle names and suffixes, because mismatched names break the court’s case-management software.
Type the petitioner’s full legal name on the Petitioner line, the respondent’s full legal name on the Respondent line, and any third-party name (such as a grandparent or DCSS) on the Other Parent or Other Parties line. Use the format Last, First Middle if that is how the original petition was filed; otherwise use First Middle Last.
For example, Lopez, Maria Elena on the petitioner line and Lopez, Daniel Jose on the respondent line keeps the caption consistent with the original FL-100 Petition. The nuance is that name changes during the case (post-marriage restoration, gender marker changes) require an amended caption, and FL-695 must use the current legal name as of the order date.
A common mistake is using nicknames, which causes the clerk’s database to flag the filing as a possible duplicate case. The misconception is that informal names are acceptable in family law forms — they are not, and the form may be rejected or, worse, served on the wrong person.
Field 4: Case Number (Top-Right Caption Box)
This is the unique number assigned by the court when the case was opened. It is the single most important data point on the form because every filing in your case is indexed by this number.
Write the case number exactly as it appears on the original Petition or on the most recent court order, including all letters, digits, and hyphens. California case numbers vary by county — Los Angeles uses formats like 24STFL01234, while San Diego uses 24FL001234N.
For example, Maria Lopez writes 24STFL01234 in the case-number box because that is the number printed on her FL-100 Petition. The nuance is that consolidated cases sometimes have a lead case number and a related case number — always use the lead number on FL-695 unless the court has ordered otherwise.
A common mistake is transposing digits, which causes the form to be filed in the wrong case file, where it sits unread for months. The misconception is that the clerk will fix a wrong number — they will not, and the burden is on the filer to refile.
Field 5: Body Text — Notice of Rights and Responsibilities
The body of FL-695 is preprinted statutory text that does not change. It states that each parent must give the other written notice of any health-care expense, that reimbursement is due within 30 days, and that disputes go to the court or to mediation under Family Code section 4063.
You do not type anything in this section. Read it carefully and confirm that the preprinted percentages — usually 50% each — match the percentages in your child support order. If your order allocates costs differently (for example 70/30), you must attach a separate page that overrides the default language and references the order.
For example, Marcus Johnson’s order allocates uninsured costs 60/40 because of his higher income, so he attaches an additional page citing paragraph 9 of his FL-342 attachment and titled Attachment to FL-695 — Custom Allocation. The nuance is that the body language references reasonable uninsured costs, and what is reasonable is litigated case by case.
A common mistake is striking out preprinted language with a pen, which voids the form because Judicial Council forms cannot be modified that way. The misconception is that the body text is negotiable between parents; it is statutory, and only the court can modify it through a separate order.
Field 6: Health-Care Coverage Assignment Lines
These lines identify which parent provides health insurance for the children. The court uses this to enforce Family Code section 3751, which requires health coverage when it is available at no or reasonable cost.
Write the providing parent’s name, the insurance carrier, the policy number, and the group number on the assignment lines. If both parents have coverage, list the primary carrier first based on the birthday rule (the parent whose birthday falls earlier in the calendar year).
For example, Janet Williams, Kaiser Permanente, Policy 0123456789, Group 9988 identifies Janet as the providing parent in a long-marriage case. The nuance is that Medi-Cal counts as health coverage for purposes of this field, so a parent enrolled in Medi-Cal writes Medi-Cal with the Beneficiary Identification Number, as explained on the Medi-Cal eligibility page.
A common mistake is leaving the group number blank because most parents do not memorize it, which causes claims to be denied at the pharmacy counter. The misconception is that the policy number alone is enough — most California carriers require both the policy and group number on every claim.
Field 7: Date and Judicial Officer Signature Block
The bottom of the form is signed by the judicial officer — usually a judge, commissioner, or referee — when the support order is signed. The date entered is the date the order is signed, not the date FL-695 was prepared.
You leave this block blank when you submit the form. The clerk will route it to the assigned judicial officer along with the proposed support order, and the officer will date and sign both at the same time. After signing, the clerk conforms the form and returns a copy to each party.
For example, Hon. Patricia Nguyen, Judge of the Superior Court, March 14, 2026 appears on Maria Lopez’s signed form once her stipulated judgment is approved. The nuance is that in DCSS Title IV-D cases the signature can be from a child support commissioner under Family Code section 4251.
A common mistake is signing the form yourself or having a notary sign it — neither has any legal effect, and the clerk will reject the filing. The misconception is that FL-695 is a contract between parents; it is a court order attachment, and only the court signs it.
Three Filled-Out Examples Using Real Scenarios
Walking through complete examples helps make the abstract fields concrete. Each scenario below tracks one named filer through the form, including the underlying support order, the percentage allocation, and the health insurance configuration. All three use the current FL-695 PDF and the California Family Code as the legal anchor.
Scenario 1: Maria Lopez — Short Marriage, W-2 Employed Co-Parent
Maria Lopez and Daniel Lopez divorced after a 5-year marriage with one child, age 4. Maria has primary custody and Daniel works as a salaried teacher. Their stipulated judgment allocates uninsured medical costs 50/50.
| Form Section | What Maria Enters |
|---|---|
| Attorney or Party Without Attorney | Maria Elena Lopez, 1428 Sunset Blvd, Los Angeles, CA 90026, (213) 555-0142, In Pro Per |
| Superior Court of California, County Of | LOS ANGELES, 111 N Hill St, Los Angeles, CA 90012, Stanley Mosk Courthouse |
| Petitioner | Lopez, Maria Elena |
| Respondent | Lopez, Daniel Jose |
| Case Number | 24STFL01234 |
| Body Text Allocation | Preprinted 50/50 — no attachment needed |
| Health-Care Coverage | Daniel Lopez, Anthem Blue Cross PPO, Policy 555888777, Group 4421 |
| Date and Judicial Officer | Left blank — signed 03/14/2026 by Hon. Patricia Nguyen |
Scenario 2: Janet Williams — Long Marriage, Self-Employed Co-Parent
Janet Williams and Robert Williams divorced after 22 years with two children, ages 14 and 17. Robert is a self-employed contractor with variable income. The court ordered a 60/40 allocation because Robert’s imputed income is higher.
| Form Section | What Janet Enters |
|---|---|
| Attorney or Party Without Attorney | Hannah Reyes, SBN 287654, Reyes Family Law, 700 K St, Sacramento, CA 95814 |
| Superior Court of California, County Of | SACRAMENTO, 3341 Power Inn Rd, Sacramento, CA 95826, Ridgeway Family Courthouse |
| Petitioner | Williams, Janet Marie |
| Respondent | Williams, Robert Allen |
| Case Number | 24FL00876 |
| Body Text Allocation | Preprinted 50/50 overridden by Attachment to FL-695 — Custom 60/40 Allocation |
| Health-Care Coverage | Janet Williams, Kaiser Permanente, Policy 0123456789, Group 9988 |
| Date and Judicial Officer | Left blank — signed 04/02/2026 by Hon. Linda Chen, Commissioner |
Scenario 3: Aisha Carter — Domestic Partnership With Arrears
Aisha Carter and Jordan Carter dissolved a registered domestic partnership with one child, age 8. There are $4,200 in uninsured medical arrears from before the order. Allocation is 50/50.
| Form Section | What Aisha Enters |
|---|---|
| Attorney or Party Without Attorney | Aisha Carter, 220 Mission St, San Francisco, CA 94105, (415) 555-0199, In Pro Per |
| Superior Court of California, County Of | SAN FRANCISCO, 400 McAllister St, San Francisco, CA 94102, Civic Center Courthouse |
| Petitioner | Carter, Aisha Renee |
| Respondent | Carter, Jordan Taylor |
| Case Number | FDI-24-812345 |
| Body Text Allocation | Preprinted 50/50 — separate Income Withholding Order handles arrears |
| Health-Care Coverage | Jordan Carter, Blue Shield HMO, Policy 778899001, Group 5566 |
| Date and Judicial Officer | Left blank — signed 05/06/2026 by Hon. Marcus Bell |
How to File the Completed Form
FL-695 is filed together with the proposed support order, never on its own. That means the filing process for FL-695 is the same as the process for filing your FL-342 Child Support Information and Order Attachment and the underlying judgment or stipulation. There is no separate filing fee for FL-695 because the fee is tied to the underlying case.
For in-person filing, take three sets of the complete order packet to the family law clerk’s window in the courthouse listed on your caption block. Counties like Los Angeles Superior Court accept filings at multiple branches; check the county website for the right family law window. Bring a self-addressed stamped envelope so the clerk can mail your conformed copy back. Processing time at the window is typically same-day for filing, with judicial signature within 5 to 30 days.
For mail filing, send the packet to the family law division at the courthouse listed on your caption. Include a cover letter, three copies, and a self-addressed stamped envelope. Acceptable payment for any related fees is by check or money order made payable to the Clerk of the Superior Court; the clerk will not accept cash by mail. Processing time is 2 to 6 weeks.
For e-filing, log in to your county’s chosen vendor — most use Odyssey eFileCA or One Legal — and upload a flattened PDF. Pay any related fees by credit card or trust-account ACH. The system returns an electronic conformed copy within 24 to 72 hours, which is your proof of filing. For DCSS Title IV-D cases, the local child support agency files FL-695 on your behalf as part of the DCSS case-opening packet, and you receive a conformed copy in the mail.
What Happens After You File
Once the clerk receives the packet, the form is routed to the assigned judicial officer for signature. The officer reviews the support order and FL-695 together. If both pass review, the officer signs them on the same date, the clerk conforms them with a stamp, and copies are mailed or e-served to both parents and any attorney of record under California Rules of Court rule 2.251.
After service, the 30-day reimbursement clock starts running every time a parent pays an uninsured medical bill. The paying parent must give the other parent written proof of the cost — a copy of the bill, the explanation of benefits, and proof of payment — and the receiving parent has 30 days to pay their share. If the receiving parent refuses, the paying parent can file an FL-490 Request for Order to enforce reimbursement, or in serious cases an FL-410 Order to Show Cause for Contempt.
DCSS cases follow the same timeline but with agency oversight. The local child support agency tracks compliance and can add unreimbursed medical costs to a wage assignment, capped by the federal CCPA limits of 50% to 65% of disposable earnings depending on the obligor’s family situation. Parents who move out of state are still bound by the California order under the Uniform Interstate Family Support Act.
Mistakes to Avoid When Filling Out the Form
Even though FL-695 is short, the consequences of filling it out wrong can echo for years. Below are the ten most common mistakes filers make at the family law facilitator’s office in California superior courts, with the direct consequence of each.
- Striking through the preprinted statutory text — this voids the form and forces a refile.
- Leaving the case number blank or transposing digits — your filing lands in the wrong file.
- Using a nickname instead of legal names — the clerk’s system flags a duplicate case.
- Writing in cursive instead of typing — illegible filings are rejected at the window.
- Skipping the health-insurance group number — pharmacy claims are denied at the counter.
- Signing the form yourself — only a judicial officer’s signature has legal effect.
- Forgetting to attach a custom-allocation page when the order is not 50/50 — costs default to 50/50.
- Using an outdated revision of the form — pre-2012 versions are rejected statewide.
- Filing FL-695 alone without the underlying support order — the clerk has nothing to attach it to.
- Failing to keep proof of service — you cannot enforce reimbursement without it.
Do’s and Don’ts
A few rules of thumb keep filers out of trouble with both the Judicial Council and the receiving parent.
Do’s:
- Do download the form fresh from courts.ca.gov each time you file because revisions change without notice.
- Do confirm the January 1, 2012 revision date in the lower-left corner before you type a single character.
- Do match the case caption exactly to the original FL-100 Petition so the clerk’s system pairs the filings.
- Do attach a separate page if your order allocates costs anything other than 50/50 because the preprinted text is the default.
- Do keep a hard copy of the conformed form for at least 18 years after the youngest child’s birth so you can enforce reimbursement.
- Do request an electronic conformed copy when e-filing because it is your only proof of filing date.
Don’ts:
- Don’t sign FL-695 yourself because only the judicial officer’s signature carries legal weight.
- Don’t strike or alter the preprinted statutory body language because that voids the form.
- Don’t file FL-695 without the underlying support order because the clerk will reject it.
- Don’t use a P.O. Box alone if local rules require a physical address for service.
- Don’t rely on memory for policy and group numbers because pharmacies and providers need both exactly right.
- Don’t ignore the 30-day reimbursement window after service because missed deadlines weaken contempt actions.
Pros and Cons of Filing on Your Own vs. With Help
Many California parents file FL-695 on their own through the Family Law Facilitator’s Office, but professional help is sometimes the safer call.
Pros of filing pro se:
- Filing yourself costs nothing beyond the underlying case fees.
- The Family Law Facilitator’s Office offers free walk-in help in every California county.
- Pro se filers learn the case file inside-out, which helps with future enforcement.
- The form is short enough that most parents can complete it in 30 minutes.
- Self-help packets at courts.ca.gov walk through the entire support-order process in plain English.
Cons of filing pro se:
- A single typo in the case number can delay the support order by weeks.
- Without an attorney, custom allocations like 60/40 are easy to draft incorrectly.
- Pro se filers often miss the requirement to e-file flattened PDFs, leading to bounced filings.
- Enforcement motions later are harder to win without a clean paper trail from the start.
- Self-employed obligors and complex insurance setups expose pro se filers to costly errors.
FAQs
Is California Form FL-695 mandatory for every child support order?
Yes. Family Code section 4063 requires the notice in every order, and the Judicial Council form is the standard vehicle.
Do I sign FL-695 myself before filing?
No. Only the judicial officer signs FL-695, and the date entered is the date the support order is signed.
What revision date should I use?
Yes, use the January 1, 2012 revision printed in the lower-left of the official PDF because it is the current active version.
Can I write the case number in pencil if I am not sure of it?
No. The case number must be typed or written in dark ink exactly as it appears on the original petition.
Do I list both parents’ insurance in the health-care coverage block?
Yes, if both have available coverage, list the primary first under the birthday rule and the secondary on the next line.
Is there a filing fee for FL-695 by itself?
No. FL-695 is filed with the support order and shares its fee status; there is no separate fee.
Do I need to attach FL-695 when I e-file the support order?
Yes. Upload the flattened PDF together with the proposed order through Odyssey eFileCA or One Legal.
Can a domestic partnership case use FL-695?
Yes. Registered domestic partnerships with shared children use the same form under Family Code section 297.5.
Do I write the petitioner’s name as last-first or first-last in Field 3?
Yes, match the format used on the original FL-100 Petition so the caption stays consistent.
What if my order is not 50/50 — do I edit the body text?
No. Never edit the preprinted text; instead attach a custom-allocation page referencing the support order paragraph.
Does Medi-Cal count as health insurance for the coverage block?
Yes. Enter Medi-Cal and the Beneficiary Identification Number from the DHCS Medi-Cal page.
How long do I keep the conformed FL-695?
Yes, keep it at least until the youngest child turns 18 plus the longest reimbursement statute, which is generally 18 years from the date of payment.
Can DCSS file FL-695 for me?
Yes. In Title IV-D cases the local child support agency files FL-695 with the support order as part of the DCSS case-opening packet.
Do I serve FL-695 separately on the other parent?
No. The clerk serves the conformed FL-695 with the support order under California Rules of Court rule 2.251.
Related reading
- How to Fill Out California Form FL-191 (w/Examples) + FAQs
- How to Fill Out California Form FL-192 (w/Examples) + FAQs
- How to Fill Out California Form FL-342 (w/Examples) + FAQs
- How to Fill Out California Form FL-610 (w/Examples) + FAQs
- How to Fill Out California Form FL-630 (w/Examples) + FAQs
- How to Fill Out California Form FL-664 (w/Examples) + FAQs
- How to Fill Out California Form FL-120 (w/Examples) + FAQs