ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY TELEPHONE NO.: ATTORNEY FOR (Name): E-MAIL ADDRESS (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF FRESNO Juvenile Dependency Department 1100 Van Ness Avenue Fresno, CA 93724-0002 (559) 457-4810 CHILDREN'S NAMES: JUVENILE LAW ­ FINANCIAL DECLARATION CASE NUMBER(S): 1. Personal Information: Social Security Number: Name: Other names used: Relationship to Child: Address: City: Zip: Phone: Mother Father I.D. or Driver's License: Date of Birth: Alternate Phone: Age: Other Responsible Party (specify): 2. I receive (check all that apply): Medi-Cal Food Stamps SSI SSP County Relief/General Assistance IHSS (In-Home Supportive Services) CalWORKS or Tribal TANF (Tribal Temporary Assistance to Needy Families) CAPI (Case Assistance Program for Aged, Blind and Disabled) 3. My gross monthly household income (before deductions for taxes) is less than the amount listed below: Family Size 1 2 4. Family: a. b. c. d. Marital Status: Single Married Divorced Separated Widowed Domestic Partner Family Income $1,134.38 $1,532.29 Family Size 3 4 Family Income $1,930.21 $2,328.13 Family Size 5 6 Family Income $2,726.04 $3,123.96 If more than 6 people in family, add $397.92 for each extra person. Name of Spouse/Partner: Number of Dependents Living with You: Dependents' Names and Ages: PJV-12 R12-11 MANDATORY JUVENILE LAW ­ FINANCIAL DECLARATION American LegalNet, Inc. www.FormsWorkFlow.com CHILDREN'S NAMES: RESPONSIBLE PARTY'S NAME: CASE NUMBERS: 5. Employment: Your Employment Employer: Address: Employer: Address: Spouse/Partner Employment City and Zip: Type of Job: How long employed: Working Now? Phone: City and Zip: Type of Job: Phone: Monthly Salary: Take home pay: How long employed: Working Now? Monthly Salary: Take home pay: If not now employed, who was last employer? (Name, Address and Zip Code) If not now employed, who was last employer? (Name, Address and Zip Code) Phone number of last employer: Phone number of last employer: 6. Income and Asset: Other Income What do you own? Cash.................................................. $ Real Property/Equity............................. $ Cars and Other Vehicles........................ $ Life Insurance...................................... $ Bank Accounts (list below)..................... $ Stocks and Bonds................................. $ Business Interest.................................. $ Other Assets....................................... $ 0.00 Total $ 0.00 Unemployment and Disability................ $ Social Security/SSI/SSP/SSD................ $ CalWORKS/Tribal TANF...................... $ General Relief.................................... $ Worker's Compensation....................... $ Child Support Payments...................... $ Foster Care....................................... $ Other Income.................................... $ Total $ Name and branch of bank Account Numbers PJV-12 R12-11 MANDATORY JUVENILE LAW ­ FINANCIAL DECLARATION American LegalNet, Inc. www.FormsWorkFlow.com CHILDREN'S NAMES: RESPONSIBLE PARTY'S NAME: CASE NUMBERS: 7. Expenses List your monthly household expenses Rent or Mortgage Payment.............. $ Car Payment................................. $ Gas and Car Insurance................... $ Public Transportation...................... $ Utilities (Gas, Electric, Phone, Water). $ Food........................................... $ Clothing and Laundry..................... $ Child Care.................................... $ Child Support Payments.................. $ Medical Payments.......................... $ Other Necessary Monthly Expenses.. $ Total $ 0.00 Monthly cost of services required by your reunification plan Parenting Classes............................ $ Substance Abuse Treatment.............. $ Therapy/Counseling......................... $ Medical Care/Medications.................. $ Domestic Violence Counseling............ $ Batterer's Intervention....................... $ Victim Support................................. $ Regional Center Programs................. $ Transportation................................. $ In-Home Services............................ $ Other............................................. $ Total $ 0.00 8. Loan/Expense Payments Name of lender and type of loan/expense $ $ $ $ Monthly payment $ $ $ $ Balance owed 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 OF RESPONSIBLE PARTY) (SIGNATURE OF RESPONSIBLE PARTY) FOR FINANCIAL EVALUATOR USE ONLY TOTAL INCOME TOTAL EXPENSES NET DISPOSABLE INCOME $ $ $ FEES BASED ON UNIFORM COST MODEL MONTHLY PAYMENT TOTAL FEES ASSESSED $ $ $ PJV-12 R12-11 MANDATORY JUVENILE LAW ­ FINANCIAL DECLARATION American LegalNet, Inc. www.FormsWorkFlow.com