ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address): TELEPHONE NO.: FOR COURT USE ONLY ATTORNEY FOR (Name) SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: IN RE THE MATTER OF: CASE NUMBER FINANCIAL RESPONSIBILITY DECLARATION Step 1 Attachments to this summary I have completed [ ] Income (page 2) [ ] Expense (page 3) [ ] Child Support (page 4) Information forms. (If child support is not an issue, do not complete Page 4. If your only income is TANF, do not complete Page 2.) 1. Are you receiving or have you applied for or do you intend to apply for welfare or TANF? Receiving [ ] Applied for [ ] Intend to apply for [ ] No 2. What is your date of birth (month/day/year)? ......................................................... ..................___________________ 3. What is your occupation? ___________________________________________________________________________ 4. Highest year of education completed: 5. Are you currently employed? [ ] Yes [ ] No a. If yes: (1) Where do you work? (name and address):________________________________________________ _____________________________________________________________________________________________ (2) When did you start work there (month/year)?.......................................................__________________ b. If no: (1) When did you last work (month/year)?...................................................................__________________ (2) What were your gross monthly earnings? ............................... ___________________ 6. What is the total number of minor children you are legally obligated to support? ........................___________________ Step 2 Answer all questions that apply to you Step 3 Income Monthly information 7. Net monthly disposable income (from line 16a of Page 2): .............................. 8. Current net monthly disposable income (if different from line 7, explain below or on Attach ment8):,................................................................... $ $ Step 4 Expense Information Step 5 Other party's Income 9. Total monthly expenses from line 2q of Page 3: ..................................................................... ........$ ______________ 10. Amount of these expenses paid by others: ...............................................................................$_______________ 11. My estimate of the other party's gross monthly income is: .............................................................$_______________ Step 6 Date and sign this form I declare under penalty of perjury under the laws of the State of California that the foregoing and the attached information forms are true and correct. Date:______________________ ______________________________________________________________________ (TYPE OR PRINT NAME) ________________________________________________________________________ (SIGNATURE OF DECLARANT) [ ] Petitioner [ ]Respondent Page 1 of 4 FINANCIAL RESPONSIBILITY DECLARATION Local Form J-4 American LegalNet, Inc. www.FormsWorkflow.com IN RE THE MATTER OF: INCOME INFORMATION OF CASE NUMBER: 1. Total gross salary or wages, including commissions, bonuses, and overtime paid during the last 12 months: 1. $__________ 2. All other money received during the last 12 months except welfare, TANF, Specify sources below: SSI, spousal support from this marriage, or any child support. __________________________ 2a. $__________ Include pensions, social security, disability, unemployment, military basic allowance for quarters (BAQ), spousal support from a different ___________________________ 2b. $___________ marriage, dividends, interest or royally, trust income, and annuities. Include income from a business, rental properties, and reimbursement ___________________________ 2c. $___________ of job-related expenses Prepare and attach a schedule showing gross receipts less cash expenses for each business or rental property _________________________ 2d. $__________ $___________ 3. Add lines 1 through 2d ............................................................................................................................................. 3 Divide line 3 by 12 and place result online 4a. Average last 12 months 4. Gross income ....,......................................................................................... 5. State income tax 6. Federal income tax ................................................................................ .............................................................................. 4a. $_____________ 5a. $_____________ 6a. $_____________ 7a. $_____________ 8a. $_____________ 9a. $_____________ 10a. $_____________ 11a. $_____________ Last month: 4b. $_____________ 5b. $_____________ 6b. $_____________ 7b. $_____________ 8b. $_____________ 9b. $_____________ 10b. $_____________ 11b. $_____________ 7. Social Security and Hospital Tax ('FICA' and "MEDI" or self-employment tax, or the amount used to secure retirement or disability benefits...... 8. Health insurance for you and any children you are required to support .. 9. State disability insurance ..................................................................... 10. Mandatory union dues........,...................,............................................ 11. Mandatory retirement and pension fund contributions ....................... Do not include any deduction claimed in item 7. 12. Court-ordered child support, court-ordered spousal support, and voluntarily paid child support in an amount not more than the guideline amount, actually being paid for a relationship other than that involved in this proceeding: 12a. $_____________ 13a. $_____________ 14a. $_____________ 12b. $______________ 13b. $______________ 14b. $______________ 14 Hardship deduction (Line 4d on Page 4) .............................................. 15. Add lines 5 through 14...........................Total monthly deductions: 16. Subtract line 15 from line 4. .......Net monthly disposable income: 15a. $_____________ 15b. $______________ 16a. $______________ 16b. $______________ 17. TANF, welfare, spousal support from this marriage, and child support from other relationships id each month: ............................................................................................................................................17. $_______________ 18. Cash and checking accounts:........................................................................................