CONFIDENTIAL Attorney or Party without Attorney (Name and Address) Telephone Number For Court Use Only Attorney for (Name): Superior Court of California, County of Solano Street Address: 600 Union Avenue City, State, and Zip: Fairfield, CA 94533 Branch Name: Juvenile CHILDREN'S NAMES: PRE­SCREEN FINANCIAL DECLARATION (JUVENILE DEPENDENCY) 1. Please give the court the following information about you: Case Number: Name: If you have ever used other names, please list them here: Relationship to Child: Current address: Date of Birth: Age: City: Zip: Phone: Alternate Phone: Yes No Are you in a California registered domestic partnership? Yes Are you married? Name of Spouse/Partner: How many people live with you that depend on you for their support? What are those persons' names and ages? No 2. Do you receive any public assistance or welfare because you have low or no income? Check one: No go on to Question 3 Yes answer additional question below, then sign at the bottom of the form and give it to the clerk I receive (check all that apply): Medi-Cal SNAP (food stamps) SSI SSP County Relief/General Assistance CalWorks or Tribal TANF (Temporary Assistance for Needy Families) IHSS (In-Home Supportive Services) CAPI (Cash Assistance Program for Aged, Blind and Disabled) ____________________________________________________ 3. Is your gross monthly household (income before taxes) less than the amount listed below for your family size? Check one: No go on to Question 4 Yes sign at the bottom of the form and give it to the clerk Family Size 1 2 Family Income $1,196.88 $1,615.63 Family Size 3 4 Family Income $2,034.38 $2,453.13 Family Size 5 6 Family Income $2,871.88 $3,290.63 If more than 6 people at home, add $412.50 for each extra person. 4. If you've answered "no" to both questions 2 and 3, you must complete a Financial Evaluation-- Juvenile Dependency form (Judicial Council JV-132). I declare under penalty of perjury under the laws of the State of California that the above information is true and correct. Date: Signature PRE-SCREEN FINANCIAL DECLARATION ­ JUVENILE DEPENDENCY Local Form 6025 Eff. 07/2013 Welfare and Institutions Code, § 903.1, 903.45(b), 903.7 www.courts.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com