SHORT TITLE CASE NUMBER DECLARATION REGARDING CHILD SUPPORT FACTORS I, State of California as follows: 1. 2. 3. 4. 5. Party Information: I am the Number of Children: I have custodial , declare under penalty of perjury under the laws of the non-custodial parent in this case. minor child(ren) with the other party. %. The other parent's timeshare is HHMFJ. I earn $ MFSper hour and I work %. Timeshare: My timeshare with my child(ren) is Filing Status: My tax filing status is: S- Wages and Salary: My average gross monthly income is $ an average of hours per week. 6. 7. Self-Employment Income: I am self-employed and I earn an average of $ Other Taxable Income: Other (specify) Disability - $ per month. $ gross per month. Not applicable. Unemployment - $ adjusted gross per month. per month. per month. 8. 9. New Spouse Income: $ Health Insurance: $ per month. Union Dues: $ per month. 10. Other Child Support Paid: I pay $ per month child support for children of another relationship that do not live with me. (Supporting evidence attached.) 11. Hardship Deduction(s) Requested: I request a hardship deduction for that live with me and whom I support. (Supporting evidence attached.) 12. Other Parent's Income: The other parent works and based upon information and belief earns $ tax filing status is . OR The other parent does not work but has the ability to work and earn $ that the court impute income to him/her. 13. Other Parent's New Spouse's Income: $ gross per month. minor children not of this relationship gross per month. His/her gross per month. I request Not applicable. 14. Child Support Add-Ons: Child Care I request 50% of the total monthly child care expenses be paid by the other party. I request $ per month child care expenses be paid by the other party. Unreimbursed Health Care Expenses - I request 50% of the total expenses be paid by the other party. 15. Other Facts: Date: Signature SDSC FLF-014 (New 2/11) DECLARATION REGARDING CHILD SUPPORT FACTORS American LegalNet, Inc. www.FormsWorkFlow.com