COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. Case Name :Case No. Index No. : Plaintiff(s) : : Calendar No. D.A. File No. DECLARATION IN SUPPORT OF DISSOMASTER T M CALCULATIONS JUDICIAL SUBPOENA I, 1. -against- HEREBY DECLARE AS FOLLOWS: I am the Petitioner/Respondent in the above entitled matter. I have personal knowledge of all the matters : set forth herein, except as to those matters stated upon information and belief, as to those matters, I believe : them to be true. Defendant(s) : . There .is/are. . . . . . . . . . . . . . . . . . . .minor .child(ren) .of. this .relationship. ..... .... ..... ........ . ... .. 2. 3. THE PEOPLE OF THE STATE OF NEW YORK I have primary physical custody of the child(ren) approximately other parent. % of the time, as compared to the 4. TO My federal income tax filing status is: single married filing separately head of household with exemption(s). My gross monthly income is married filing Jointly 5. , from the following sources: . GREETINGS: Regular wages and salary WE COMMAND YOU, that all business and excuses being. laid aside, you and each of you attend before Self-employment income (After the cost of doing business) , the Honorable at the Court . Source located at County of Other in room , on the day of , 20 , at o'clock in the noon, and at any recessed Irregular testify . or adjourned date, toincomeand give evidence as a witness in this action on the part of the 6. I have the following regular monthly deductions or expenses: Mandatory retirement Medical Insurance costs Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to 401K or behalf this subpoena was Child and the party on whose deferred compensation issued for a maximum penalty of $50 careall damages sustained as a result of your failure to comply. Mortgage interest Property Tax Union dues Child support/spousal support paid to another relationship Witness, Honorable Court in County, day of , 20 7. 8. 9. 10. I estimate the other party's gross monthly income to be I support other child(ren) of mine, in my home. other child(ren) of , one of the Justices of the Based on (Attorney must sign above and type name below) I receive support for Attorney(s) for I am experiencing extreme financial hardship(s) caused by: and I request the Court grant me a monthly deduction in the amount of Office and P.O. Address to accommodate these circumstances. I hereby declare under penalty of perjury under the laws of the State of California, that the foregoing statements are true and correct. Executed in Ventura County on Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: . Optional Form VN115 Rev. 07/01/03 Signature American LegalNet, Inc. www.USCourtForms.com