SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE INDIO 47-671 Oasis St., Indio, CA 92201 MURRIETA 30755-D Auld Rd. Ste. 1226, Murrieta, CA 92563 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number and Address) RIVERSIDE 9991 County Farm Rd., Riverside, CA 92503 RI-JV011 FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): CHILD'S NAME: CASE NUMBER: PARENT/GUARDIAN'S FINANCIAL STATEMENT AND NOTICE ELIGIBILITY FOR APPOINTMENT OF COUNSEL REIMBURSEMENT FOR COST OF COURT APPOINTED COUNSEL 1. a. b. c Parent/Guardian's name: Other names used: Address: d. e. f. g. Date of birth: Telephone number: Driver's License No. Social Security No.: 2. 3. I am am not married Spouse/Domestic Partner's Information a. Name: b. Other names used: c. Address: Parent/Guardian's Present Employment: a. Occupation: b. Name of Employer: c. Address: d. Gross pay per month: $ e. Take home pay per month: f. Name of union: d. e. f. Date of birth: Telephone No.: Driver's license No.: 4. week: $ day:$ 5. If you are not now working, state the name and address of your last employer and the last day you were employed. a. Name: b. Address: c. Last date of employment: Spouse/Domestic Partner's Present Employment a. Present Employment: b. Occupation: c. Name of employer: 6. Page 1 of 3 Approved for Optional Use Riverside Superior Court RI-JV011 [Rev.03/13/13] PARENT/GUARDIAN'S FINANCIAL STATEMENT AND NOTICE riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com CHILD'S NAME: CASE NUMBER: c. d. e. f. 7. Address: Gross pay per month: $ Take home pay per month: Name of union: week: $ $ week: $ day:$ day:$ If your spouse/domestic partner is not now working, state the name and address of his/her last employer and the last day he/she was employed. a. Name of employer: b. Address: c. Last date of employment: Your dependents (people your support) Name 8. Address Relationship Age 9. Parent/Guardian a. Unemployment b. Social Security (SSI, SSP) c. TANF d. Veteran's benefits e. Worker's Compensation f. Child support payments g. Spousal support payments h. CalFresh (Food Stamps) i. All other income not elsewhere listed TOTAL $ $ $ $ $ $ $ $ $ $ OTHER MONTHLY INCOME Spouse/Domestic Partner a. Unemployment b. Social Security (SSI, SSP) c. TANF d. Veteran's benefits e. Worker's Compensation f. Child support payments g. Spousal support payments h. CalFresh (Food Stamps) i. All other income not elsewhere listed TOTAL $ $ $ $ $ $ $ $ $ $ 10. EXPENSES Monthly expenses being paid by parent/guardian (either alone or jointly with spouse/domestic partner): a. Rent/House payment $ f. Clothing/laundry $ b. Car payment $ g. Food $ c. Transportation payment $ h. Support payment $ d. Medical/Dental payment $ I. Insurance payment $ e. Loan payment $ j. Other payment (union, taxes $ TOTAL (a-j) $ Page 2 of 3 Approved for Optional Use Riverside Superior Court RI-JV011 [Rev.03/13/13] PARENT/GUARDIAN'S FINANCIAL STATEMENT AND NOTICE riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com CHILD'S NAME: CASE NUMBER: 11. Installment payments (including credit cards) other than those listed in item 10. Name of Creditor Monthly Payment a. a. b. b. c. c. d. d. e. e. TOTAL $ ASSETS What do you own? (Sate value) a. Cash b. Home equity c. Cars, other vehicles and boat equity (list make, year and license number of each) Balance Owed $ $ $ $ $ $ 12. a. b. c. $ $ $ d. Checking, savings and credit union accounts (list name and account number of each; List the total of all accounts below) Name of Account Account Number e. f. g. h. Other real estate equity Income tax refunds due Life Insurance Policies (Ordinary life-face value) Other personal property (jewelry, furniture, furs, stocks and bonds etc.) TOTAL d. e. f. g. h. $ $ $ $ $ $ Length of ownership 13. ELIGIBILITY FOR APPOINTMENT OF COUNSEL AND NOTICE TO PARENT/GUARDIAN: If an attorney is appointed to represent your child, the court will, at the conclusion of the proceedings, after the hearing, make a determination of your ability to pay all or a portion of the cost of the attorney. Such an order will have the same force and effect as a judgment in a civil action and will be subject to execution. Declaration of Parent/Guardian I declare under penalty of perjury that the foregoing is true and correct and that I understand the notice contained in Item 13 and that this declaration was executed on: at (County) (DATE) , California. (SIGNATURE OF PARENT/GUARDIAN) Page 3 of 3 Approved for Optional Use Riverside Superior Court RI-JV011 [Rev.03/13/13] PARENT/GUARDIAN'S FINANCIAL STATEMENT AND NOTICE riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com