ATTORNEY OR PARTY WITHOUT AN ATTORNEY (Name, State Bar number and address): FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN MATEO STREET ADDRESS: YOUTH SERVICES CENTER MAILING ADDRESS: 222 PAUL SCANNELL DRIVE CITY AND ZIP CODE: SAN MATEO, CA 94402 BRANCH NAME: JUVENILE CHILDREN'S NAMES: CASE NUMBERS: FINANCIAL DECLARATION ­ JUVENILE DEPENDENCY 1. Personal Information: Name: Other names used: Relationship to Child: Mother Father Other Responsible Party (specify): Address: City: Zip: Phone: I.D. or Drivers License: Date of Birth: Alternate Phone: Age: Social Security Number: 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: Page 1 of 3 Form adopted for Mandatory Use Local Court Form JV-12 [New September 2011] Financial Declaration ­ Juvenile Dependency W&I § 903.47(a) www.sanmateocourt.org American LegalNet, Inc. www.FormsWorkFlow.com CHILDREN'S NAMES: RESPONSIBLE PARTY'S NAME: CASE NUBMERS: 5. Employment: Your Employment Spouse/Partner Employment Employer: Address: Employer: Address: 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 Assets: Other Income 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 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...............................................$ ______________ Total $ ______________ ___________________________ ___________________________ ___________________________ Page 2 of 3 Form adopted for Mandatory Use Local Court Form JV-12 [New September 2011] Financial Declaration ­ Juvenile Dependency W&I § 903.47(a) www.sanmateocourt.org American LegalNet, Inc. www.FormsWorkFlow.com CHILDREN'S NAMES: RESPONSIBLE PARTY'S NAME: CASE NUBMERS: 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 $ ______________ Monthly cost of services required by your reunification plan 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 $ ______________ 8. Loan/Expense Payments Name of lender and type of loan/expense Monthly payment $ ___________________ $ ___________________ $ ___________________ $ ___________________ Balance Owed $_____________________ $_____________________ $_____________________ $_____________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ I certify under penalty of perjury that the above information 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 $ _________________ $ _________________ FEES BASED ON UNIFORM COST MODEL $ ____________________ MONTHLY PAYMENT TOTAL FEES ASSESSED $ __