Uniform Support Affidavit Instructions for Form 6F The Uniform Support Affidavit must be completed when the payment of child support is an issue. It provides basic information about expenses and ability to pay. CAUTION: Please read the instructions for and use UTCR Form 2.100 for all forms which may contain Social Security Numbers. There may be attachments submitted with the Uniform Support Affidavit that have Social Security Numbers in them. It is your responsibility to redact (black out) any Social Security Numbers on the attachments or copies. UNIFORM SUPPORT AFFIDAVIT of  Petitioner  Respondent  Co-Petitioner - Page 1 of 10 6D-Z.MiscForms: 6F-UniformSupportAffidavit.Ver07.doc (2/08) American LegalNet, Inc. www.FormsWorkflow.com IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF _____________ In the Matter of: ) ) ) ________________________________________, ) Petitioner, ) ) ) AND ) ) ________________________________________, )  Respondent  Co-petitioner. ) Circuit Court No._____________________ Uniform Support Affidavit of:  Petitioner  Respondent  Co-petitioner (Child Support or Spousal Support Case) This form is a SWORN AFFIDAVIT (under oath) required for support determinations. It must be signed before a notary public, filed with the court, and served upon the other party (or their attorney). If no party seeks spousal support or a deviation (change) from the uniform child support guidelines, you need only complete the Affidavit (pages 1 through 6) and any attachments requested on those pages. If any party seeks either spousal support or any deviation (change) from the uniform child support guidelines, you must complete not only the Affidavit (pages 1 through 6) and any attachments requested on those pages, but also the attached “Schedule 1 Monthly Expenses and Rebutting Factors Required.” In addition, note that certain documentation MUST be attached to this Affidavit (e.g., see pages 2 and 3). STATE OF OREGON ) ) ss. County of ________________________ ) I, _______________________, being first duly sworn under oath, depose and say that I am the_________________in the above-entitled matter and that the following are true to the best of my knowledge and belief: Petitioner/Respondent 1. 2. 3. 4. 5. 6. Your Age: Date of Birth: under UTCR 2.100 Residence Address: Name of Employer &Address: Occupation: Length of Employment: Children born of or adopted during this relationship: Social Security Number: File Title: UNIFORM SUPPORT AFFIDAVIT of □ Petitioner □ Respondent □ Co-Petitioner - Page 2 of 10 6D-Z.MiscForms: 6F-UniformSupportAffidavit.Ver07.doc (2/08) American LegalNet, Inc. www.FormsWorkflow.com Child living with: Name of Child 7. Me Other Parent Other List all people living in your household (other than children named in item 6 above): Name 8. Age Age Relationship to You Monthly Income List your other dependents or children not listed in items 6 or 7 above: Name Age Relationship to You Monthly Income 9. ENTER THE FOLLOWING INFORMATION FROM SCHEDULES INDICATED: A. TOTAL GROSS INCOME (From page 5, item 16.D.) : B. TOTAL EXPENSES OF CHILDREN (From Schedule 1, item 1.): C. TOTAL MONTHLY EXPENSES (From Schedule 1, item 6.) : 10. (a) Are you or your present spouse entitled to receive court-ordered child support for any children now living with you?  YES  NO If “YES,” complete the following and ATTACH A COPY OF ALL SUCH CHILD SUPPORT ORDERS. Name of Child Age Relation to You Support Amount __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ (b) Are those support payments being made?  YES  NO UNIFORM SUPPORT AFFIDAVIT of □ Petitioner □ Respondent □ Co-Petitioner - Page 3 of 10 6D-Z.MiscForms: 6F-UniformSupportAffidavit.Ver07.doc (2/08) American LegalNet, Inc. www.FormsWorkflow.com 11. Are you required to pay a court-ordered child support obligation for a child of yours who is not listed in item 6 above?  YES  NO If “YES,” complete the following and ATTACH A COPY OF ALL CHILD SUPPORT ORDERS. Name of Child Age Name of Recipient Monthly Support Amount __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 12. Are you ordered to pay or entitled to receive court-ordered spousal support?  YES  NO If “YES,” complete the following and ATTACH A COPY OF ALL SUCH SPOUSAL SUPPORT ORDERS. Owed To Paid By Monthly Support Amount __________________________________________________________________________________________ Owed Until:______________________________(Date or Event):_____________________________________ 13. Are you incurring child care costs on behalf of the children listed in item 6 above?  YES  NO If “YES,” complete the following and attach documentation verifying the information provided below: Name of Day-care Provider Monthly (gross amount before application child and Address cost of any tax credit or subsidy) __________________________________________________________________________________________ __________________________________________________________________________________________ 14. Do you receive any subsidy for such care? If so, amount $_________________per month. 15. MEDICAL AND DENTAL ELECTIONS – The child support recipient may elect to require the support payor to name the child(ren) as the beneficiary on a health/dental insurance plan. If so elected, the child support may be adjusted by an amount equal to all or a portion of the cost to parent who provides the child/ren’s portion of the health/dental insurance premium. Please choose:  I wish to require health/dental insurance coverage by the other party and understand that a portion of the premium may be deducted from support.  I do not wish to require health/dental insurance coverage by the other party.  I provide health/dental insurance through my employer; see page 6, item 18, of this schedule, for information. ATTACHMENTS REQUIRED OPTIONAL  Last four (4) payroll stubs.  Child care documentation if you want this considered.  Most recent federal and state income tax return.  Medical/dental insurance documentation.  Copies of any and all relevant child/spousal support orders. UNIFORM SUPPORT AFFIDAVIT of □ Petitioner □ Respondent □ Co-Petitioner - Page 4 of 10 6D-Z.MiscForms: 6F-UniformSupportAffidavit.Ver07.doc (2/08) American LegalNet, Inc. www.FormsWorkflow.com (INCOME, DEDUCTIONS AND MEDICAL/DENTAL INSURANCE) You must complete and submit the following attachments. Copies of recent: (1) federal and state income tax returns, (2) last four pay stubs, and (3) if self-employed, most recent profits and loss statement. 16. Your Monthly Gross Income: A. From Employment: If paid weekly, multiply weekly income by 4.3 to arrive at a monthly gross income and insert below. If paid every two weeks, multiple two weeks’ income by 2.15 and insert below: Description Monthly Amount Gross Hourly Wage:_________________________________ Average Number of Hours Worked Per Week:____________ Gross Monthly Income: _____________________________ Gross Monthly Tips/Commissions/Bonuses (identify): _____________________________ SUBTOTAL 16.A. _____________________________ B. From Self-Employment: If you own an interest in partnership or in a closely held corporation, attach last year’s schedule K-1 and/or corporation federal income tax return: Description Monthly Amount Gross Receipts: _____________________________ Expense Reimbursements: _____________________________ Rental Income: _____________________________ Royalty Income: _____________________________ Less Ordinary/Necessary Expenses: (____________________________) Plus Monthly Portion of Accelerated Component of any Depreciation Allowance or Investment Tax Credits: _____________________________ SUBTOTAL 16.B. C. below): _____________________________ Other Sources of Income: (Please attach verification of any income available to you as listed Description Dividends: Interest Income: Trust Income: Contract Payments (less underlying debt): Annuity Income: Retirement Benefits-Pension/IRA/ Keogh (nonsocial security): Social Security Income: Workers’ Compensation Benefits Per Week Multiplied by 4.3= Unemployment Benefits Per Week Multiplied by 4.3= Monthly Amount _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________per month _____________________per month UNIFORM SUPPORT AFFIDAVIT of □ Petitioner □ Respondent □ Co-Petitioner - Page 5 of 10 6D-Z.MiscForms: 6F-UniformSupportAffidavit.Ver07.doc (2/08) American LegalNet, Inc. www.FormsWorkflow.com Disability Income: Gift or Prizes: Spousal Support: Expense Reimbursements and/or Per Diem Allowance (not listed in item B. above): ADC Benefits: FCAS (food stamps): Other (specify): SUBTOTAL 16.C. _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ D: Summary of Your Gross Income: Description Income from Employment (item 16.A. above): Self-Employed Income (item 16.B. above): Other Income (item 16.C. above): Monthly Amount _____________________________ _____________________________ _____________________________ _____________________________ YOUR TOTAL MONTHLY GROSS INCOME: ENTER HERE and on this Affidavit Page 2, line 9.A. 16.D. _____________________________ 17. Your Monthly Deductions from Gross Income: A. Mandatory Deductions: Number or exemptions claimed by you:___________ Description Monthly Amount State Income Taxes: _____________________________ Federal Income Taxes: _____________________________ Social Security (FICA): _____________________________ Workers’ Compensation Insurance Premium: _____________________________ Wage Withholding, Wage Assignment or Garnishment: _____________________________ (Paid to:____________________________________________ ) Medical Insurance for the Parties’ Joint Children if Additional Premium Total Premium_____________– less cost of coverage for yourself + other dependants = _____________________________ SUBTOTAL OF MANDATORY: B. Optional Deductions: Description Retirement/Profit Sharing: Savings Plan: Credit Union: Other: SUBTOTAL OF OPTIONAL: 17.A. _____________________________ Monthly Amount _____________________________ _____________________________ _____________________________ _____________________________ 17.B. _____________________________ C. Summary of Deductions: UNIFORM SUPPORT AFFIDAVIT of □ Petitioner □ Respondent □ Co-Petitioner - Page 6 of 10 6D-Z.MiscForms: 6F-UniformSupportAffidavit.Ver07.doc (2/08) American LegalNet, Inc. www.FormsWorkflow.com Mandatory--from item 17.A. above: Optional--from item 17.B. above: TOTAL MONTHLY DEDUCTIONS 18. 17.C. ______________________ ______________________ ____________________________ Information for Medical and Dental Insurance Coverage: (For children listed on page 2, item 6, of this Affidavit which is currently provided or available for the benefit of those children.):  I provide this (complete information below) HEALTH INSURANCE  Other parent provides this (complete if known) Name of Insurance Company: ____________________ Plan or Group Name: ____________________ Plan/Group Number: ____________________ Individual I.D. Number: ____________________ Address for Claims Submission: ____________________ Phone Number for Information: ____________________ Amount of Annual Deductible: ____________________ Gross Monthly Premium Actually Paid by You (exclude amounts paid by your employer): ____________________ Monthly Premium to Cover Only You: ____________________ Dependent’s Portion of Monthly Premium: ____________________ DENTAL INSURANCE ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ Are there dependents other than children on page 2, item 6, of this Affidavit enrolled with plan?  YES  NO If Yes, total number or other dependants: ____________________ ____________________ Certificate of Document Preparation. You are required to truthfully complete this certificate regarding the document you are filing with the court. Check all boxes and complete all blanks that apply:  I selected this document for myself and I completed it without paid assistance.  I paid or will pay money to for assistance in preparing this form. I certify that my answers and this information on this affidavit and the attached schedules are true to the best of my knowledge and ability. I further certify that the information on the attached documents is true to the best of my knowledge and ability. Dated this _____ day of ____________________________, 20____. __________________________________________ Signature SIGNED AND SWORN to before me this ___________ day of _______________, 20 Notary Public for ____________/Court Clerk My Commission Expires: /// /// UNIFORM SUPPORT AFFIDAVIT of □ Petitioner □ Respondent □ Co-Petitioner - Page 7 of 10 6D-Z.MiscForms: 6F-UniformSupportAffidavit.Ver07.doc (2/08) American LegalNet, Inc. www.FormsWorkflow.com SCHEDULE 1 (Monthly Expenses and Rebutting Factors) You must complete this schedule and prepare and submit the attachments requested in this schedule if either party seeks spousal support or any change from the uniform child support guidelines. These are the total household expenses you must pay each month. Utility bills should be averaged over the year. Any other annual, quarterly, or other periodic payments should be converted to a monthly average. DO NOT LIST ANY EXPENSE IF IT IS DEDUCED FROM YOUR WAGES. ONLY INCLUDE DIRECT EXPENSES FOR JOINT CHILDREN IN SECTION 1. 1. Direct monthly expenses for children of this relationship which you pay: AMOUNT A. School Expenses: School Lunches: Books, Tuition: Activities: Other (Specify): B. Food (Other than school lunches): C. Day Care: D. Clothing: E. Medical Insurance--Premium Payments: F. Unreimbursed Health Costs: G. Unreimbursed Dental Costs: H. Baby--Sitting (not work-related): I. Lessons: J. Grooming Needs: K. Hobbies, Recreation: L. Entertainment: M. Allowances: N. Transportation: Gasoline, Oil: Insurance for Driving-Age Child: O. Miscellaneous (Specify):________________________ _______________________________________________ TOTAL DIRECT EXPENSES OF CHILDREN: (Add 1.A. thru 1.O.): ENTER HERE and on Uniform Support Affidavit page 2. Line 9.B. Source Average Monthly Amount of Child’s Income: 2. FIXED COSTS A. RESIDENCE: Mortgage or Rent: Property Taxes: (If not included in mortgage) Second Mortgage: Other: B. UTILITIES: Electricity: _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ 1. _______________________ Amount Name Monthly Amount ____________________ ____________________ ____________________ ____________________ ____________________ UNIFORM SUPPORT AFFIDAVIT (Schedule 1) of □ Petitioner □ Respondent □ Co-Petitioner - Page 8 of 10 6D-Z.MiscForms: 6F-UniformSupportAffidavit.Ver07.doc (2/08) American LegalNet, Inc. www.FormsWorkflow.com C. D. E. F. G. H. Heat (other than electricity): ____________________ Water: ____________________ Garbage: ____________________ Telephone: ____________________ Other: ____________________ TRANSPORTATION: Car Payments: ____________________ Gas & Oil: ____________________ Maintenance & Repairs: ____________________ Other (Specify): ____________________ INSURANCE: Life: ____________________ Automobile: ____________________ Medical/Dental: ____________________ Residence: ____________________ FOOD AND HOUSEHOLD ITEMS:____________________ (exclude food expenses for joint children covered in Schedule 1, Part 1, above) CLOTHING: ____________________ Grooming/Personal Needs: ____________________ MEDICINE AND PHARMACEUTICAL – Unreimbursed medical/dental costs:________________ COURT/DHR-ORDERED SUPPORT PAYMENTS: ________________ TOTAL FIXED COSTS (A-H): 3. 2. _____________________ CONSUMER OBLIGATIONS: NAME OF CREDITORS _________________________________ _________________________________ _________________________________ _________________________________ BALANCE DUE ______________ ______________ ______________ ______________ TOTAL MONTHLY PAYMENTS ON CONSUMER OBLIGATIONS: 4. MONTHLY PAYMENTS _____________________ _____________________ _____________________ _____________________ 3. _____________________ DISCRETIONARY EXPENSES: A. B. C. D. E. F. Entertainment: Vacations: Gifts: Religious Contributions: Dues and Subscriptions: Club Memberships & Dues: TOTAL DISCRETIONARY EXPENSES: ADDITIONAL EXPENSES: _______________________________ _______________________________ TOTAL ADDITIONAL EXPENSES: ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ 4. _____________________ 5. ____________________ ____________________ 5. ______________________ UNIFORM SUPPORT AFFIDAVIT (Schedule 1) of □ Petitioner □ Respondent □ Co-Petitioner - Page 9 of 10 6D-Z.MiscForms: 6F-UniformSupportAffidavit.Ver07.doc (2/08) American LegalNet, Inc. www.FormsWorkflow.com 6. TOTAL EXPENSES EXCLUDING DIRECT EXPENSES OF CHILD (Add 2, 3, 4 and 5): 6. _______________________ ENTER HERE and on Uniform Support Affidavit, page 2, line 9C. 7. Other factors that affect my income and expenses or that should be considered to rebut the presumptive child support Calculations (attach supporting documentation whenever possible): UNIFORM SUPPORT AFFIDAVIT (Schedule 1) of □ Petitioner □ Respondent □ Co-Petitioner - Page 10 of 10 6D-Z.MiscForms: 6F-UniformSupportAffidavit.Ver07.doc (2/08) American LegalNet, Inc. www.FormsWorkflow.com