Marital Status: SUPERIOR COURT OF CALIFORNIA, COUNTY OFBRANCH NAME:CITY AND ZIP CODE:STREET ADDRESS:MAILING ADDRESS: CHILDREN'S NAMES: FOR COURT USE ONLY CASE NUMBER: FINANCIAL DECLARATION227JUVENILE DEPENDENCYJV-132 ATTORNEY OR PARTY WITHOUT ATTORNEYSTATE:ZIP CODE:CITY:STREET ADDRESS:FIRM NAME:NAME:STATE BAR NO.:TELEPHONE NO.:FAX NO.:E-MAIL ADDRESS:ATTORNEY FOR (name):CONFIDENTIAL Name: Social Security Number: Other names used: I.D. or Driver's License Number: Date of Birth: Age: Relationship to Child:MotherFatherOther Responsible Person(specify): Street or Mailing Address: City: State: Zip: Phone: Alternate Phone: Married Single Domestic partner Separated Divorced Widowed Name of Spouse/Partner: Number of dependents living with you: Medi-CalSNAP (food stamps)SSISSPCounty Relief/General AssistanceCalWORKS or Tribal TANF (Temporary Assistance to Needy Families)IHSS (In-Home Supportive Services) CAPI (Case Assistance Program for Aged, Blind, and Disabled)My gross monthly household income (before deductions for taxes) is less than the amount listed below: Family Size Family Income Family Size Family Income Family Size Family Income 1 $1,301.05 3 $2,221.88 5 $3,142.71 2 $1,761.46 4 $2,682.30 6 $3,603.13 If more than 6 people at home, add $460.42 for each extra person.I have been reunified with my child(ren) under a court order (attached).I am receiving court-ordered reunification services. Names and ages of dependents:Form Approved for Optional Use Judicial Council of California JV-132 [Rev. March 15, 2019]Welfare and Institutions Code, 247247 903.1, 903.45(b), 903.47 www.courts.ca.govFINANCIAL DECLARATION227JUVENILE DEPENDENCY Page 1 of 3Personal Information:I receive (check all that apply): 2.3.4.5.1. American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIALJV-132 CHILDREN'S NAMES:RESPONSIBLE PERSON'S NAME: CASE NUMBER: Assets: What Do You Own?$$$$$$$$ 6. JV-132 [Rev. March 15, 2019]Page 2 of 3FINANCIAL DECLARATION227JUVENILE DEPENDENCYEmployment: Your Employment Your Spouse/Partner's Employment7.Other Monthly Income and Assets: Other Income Employer: Address: City and Zip Code: Phone: Type of Job: How long employed: Working now? Monthly salary: Take home pay: If not now employed, who was your last employer? (Name, Address, City, and Zip Code): Phone number of last employer: Employer: Address: Type of Job: City and Zip Code: Phone: How long employed: Working now? Monthly salary: Take home pay: If not now employed, who was this person's last employer? (Name, Address, City, and Zip Code): Phone number of last employer:Unemployment ...............................................$Disability ........................................................$Social Security ...............................................$Workers' Compensation ................................$Child Support Payments ................................$Foster Care Payments ...................................$Other Income .................................................$ Total $ Cash ............................................................ Real Property/Equity .................................... Cars and Other Vehicles ..............................Life Insurance .............................................. Bank Accounts (list below).............................Stocks and Bonds ........................................Business Interest .........................................Other Assets ................................................ Total $ Name and branch of bank: Account numbers: American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIALJV-132 CHILDREN'S NAMES:RESPONSIBLE PERSON'S NAME: CASE NUMBER:$ $ FOR FINANCIAL EVALUATION OFFICER USE ONLY (SIGNATURE OF DECLARANT)8.Expenses:9.Loan/Expense Payments (other than mortgage or car loan):Name of lender and type of loan/expenseMonthly paymentBalance owedI declare under penalty of perjury under the laws of the State of California that the above information is true and correct.The above-named responsible person is presumed unable to pay reimbursement for the cost of legal services in this proceeding and is eligible for a waiver of liability because JV-132 [Rev. March 15, 2019]Page 3 of 3FINANCIAL DECLARATION227JUVENILE DEPENDENCY Reunification Plan: Monthly Cost of Required Services$ Monthly Household ExpensesRent or Mortgage Payment ........................... Car Payment ................................................. Gas and Car Insurance ................................. Public Transportation .................................... Utilities (Gas, Electric, Phone, Water, etc.)....Food .............................................................. Clothing and Laundry .................................... Child Care ..................................................... Child Support Payments ............................... Medical Payments ......................................... Other Necessary Monthly Expenses ............. Total $ $Parenting Classes .........................................$Substance Abuse Treatment ........................$Therapy/Counseling ......................................$Medical Care/Medications .............................$Domestic Violence Counseling .....................$Batterers' Intervention ...................................$Victim Support ..............................................$Regional Center Programs ...........................Transportation ...............................................In-Home Services .........................................$Other .............................................................$ Total $ $$$$$$$$TOTAL INCOME $TOTAL EXPENSES $NET DISPOSABLE INCOME COST OF LEGAL SERVICES $ MONTHLY PAYMENT $TOTAL COST ASSESSED Date: (TYPE OR PRINT NAME) (SIGNATURE OF FINANCIAL EVALUATION OFFICER)he or she receives qualifying public benefits his or her household income falls below 125% of the current federal poverty guidelines he or she has been reunified with the child(ren) under a court order and payment of reimbursement would harm his or her ability to support the child(ren). Date: (TYPE OR PRINT NAME)$$$$$$$$$$ American LegalNet, Inc. www.FormsWorkFlow.com