IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR ____________________ COUNTY In the Matter of: ) ) , ) ) Petitioner Co-Petitioner, ) ) and ) ) , ) ) Respondent Co-Respondent. ) ) Case No. Judge Assigned: Check one box: PETITIONER'S RESPONDENT'S CO-PETITIONER'S CO-RESPONDENTS or OTHER: UNIFORM SUPPORT DECLARATION OR CSP Case No. SUMMARY INFORMATION ­ COMPLETE THIS PAGE LAST After completing Sections 1 through 5, on Pages 2 through 5 below, insert the information and/or total MONTHLY amounts in this Summary Information section. Date of Completion _______________ mm/dd/year 1. Number of Joint Children From This Relationship: 2. Number of Joint Children Over 18 But Under 21 Attending School: 3. Number of Nonjoint Additional Children: 4. Gross Monthly Income From All Sources: 5. Receiving Temporary Assistance for Needy Families? 6. Child(ren) on Oregon Health Plan/Healthy Kids or Other Public Health Plan? 7. Social Security or Veteran's Benefits Received for Child(ren): Person with Disability is: Child Me Other Parent 8. Spousal Support RECEIVED by You: 9. Spousal Support PAID by You: 10. Mandatory Union Dues Paid: 11. Health Care Premiums for Yourself: 12. Health Care Premiums Paid for Joint Child(ren): 13. Out-of-Pocket Medical Expenses Paid for Joint Child(ren): 14. Number of ANNUAL Overnights Child(ren) Spends With You: 15. Childcare Expenses Paid for Joint Child(ren): 16. City Where Childcare is Provided: _______________ _______________ _______________ $_______________ Yes No Yes No $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ _______________ $_______________ ____________________________________________ Page 1 - FORM 8.010.5 ­ UNIFORM SUPPORT DECLARATION OF PETITIONER RESPONDENT CO-PETITIONER CO-RESPONDENT OTHER ­ UTCR 8.010(4), 8.010(7), 8.040(3), 8.040(4), 8.050(1), 8.050(3) (Revised 12-1-14) American LegalNet, Inc. www.FormsWorkFlow.com This form is a DECLARATION under penalty of perjury required for support determinations. It must be completed in its entirety, signed, filed with the court or appropriate administrative agency, and served upon the other party (or their attorney). INSTRUCTIONS: Answer all questions. Items marked with an * should be transferred to Page 1. If you are seeking spousal support, you need to complete Schedule 1. Attach additional page if needed. IMPORTANT: This information will be disclosed to the other party and may be subject to public access. Protections are available using the court's "Confidential Information Form" process. 1. CHILDREN A. *List all JOINT CHILDREN (children under the age of 21 born or adopted during this relationship): Children Living With: Name of Child Age Me Other Parent Other Over 18 & Under 21 Attending School Yes No B. *List all NONJOINT ADDITIONAL CHILDREN (children under the age of 21 born to or adopted by you but not of this relationship). Name Age 2. YOUR GROSS INCOME A. From Your Employment: Description Monthly Amount 1 2 3 Gross hourly wage. Average number of hours worked per pay period. Convert to annual. If paid monthly, enter "12". If paid twice monthly, enter "24". Every two weeks, enter "26". Every week, enter "52". Convert to monthly. Gross monthly income: 1. x 2. x 3. ÷ 4. Gross monthly tips/commissions/bonuses (identify): SUBTOTAL: 2.A. x x 4 5 6 ÷ 12 Subtotal of Monthly Income From Employment (5) + (6) Page 2 - FORM 8.010.5 ­ UNIFORM SUPPORT DECLARATION OF PETITIONER RESPONDENT CO-PETITIONER CO-RESPONDENT OTHER ­ UTCR 8.010(4), 8.010(7), 8.040(3), 8.040(4), 8.050(1), 8.050(3) (Revised 12-1-14) American LegalNet, Inc. www.FormsWorkFlow.com B. Other Sources of Your Monthly Income: (Attach verification of your gross monthly income as listed below): Description Self-Employment Dividends Interest Income Trust Income Annuity Income Social Security Income Workers' Compensation Benefits per week multiplied by 52; divided by 12 Unemployment Benefits per week multiplied by 52; divided by 12 Disability Income Expense Reimbursements and/or Per Diem Allowance not listed in item A. above Other (specify source/type) Other (specify source/type): SUBTOTAL: 2.B. *Total of 2A + 2B Enter here and on Page 1, #4 C. *Do you receive Temporary Assistance for Needy Families? TOTAL: Yes, $________ monthly No No Monthly Amount D. *Do you receive Social Security or Veteran's benefits for any joint child(ren) due to parent's disability? Name of Beneficiary Child(ren) _______________________ Yes, $________ monthly Name of Disabled Parent ____________________________ Source E. *Do you receive Social Security or Veteran's benefits for any joint child(ren) due to child's disability? Yes, $________ monthly Name of Child(ren) _________________________________ Source F. *Is there an order for you to RECEIVE spousal support from your spouse involved in this proceeding? Yes, $________ monthly G. *Is there an order for you to RECEIVE spousal support from a former/subsequent spouse? Yes, $________ monthly H. *Are you ordered to PAY spousal support? If Yes, to whom? __________________________________ I. *Do you pay mandatory union dues? Yes, $________ monthly No J. ATTACH A COPY OF YOUR FOUR MOST RECENT PAY STUB(S), BENEFIT STATEMENTS, AND COPIES OF YOUR MOST RECENTLY FILED STATE AND FEDERAL TAX RETURNS. ATTACH COPIES OF SPOUSAL SUPPORT ORDERS AND ANY CHILD SUPPORT ORDERS FOR NONJOINT ADDITIONAL CHILD(REN) NOT LIVING WITH YOU. Yes, $________ monthly No No No No Page 3 - FORM 8.010.5 ­ UNIFORM SUPPORT DECLARATION OF PETITIONER RESPONDENT CO-PETITIONER CO-RESPONDENT OTHER ­ UTCR 8.010(4), 8.010(7), 8.040(3), 8.040(4), 8.050(1), 8.050(3) (Revised 12-1-14) American LegalNet, Inc. www.FormsWorkFlow.com 3. HEALTH CARE COVERAGE AND MEDICAL EXPENSES A. *Is there a cost to insure just yourself? B. Do you provide health care coverage for your joint child(ren)? C. Does someone else provide health care coverage for your joint child(ren)? Name of person, or entity, providing, if other than you: D. Are you or any member of your household: i. ii. Enrolled in the Oregon Health Plan, Healthy Kids, or any other public health care coverage? Yes Receiving a state subsidy for public or private health care coverage? Yes No No No Yes Yes Yes No No No E. Are any of the joint children enrolled in public health care coverage (Healthy Kids/Oregon Health Plan)? Name of child(ren) enrolled? _________________________________________ Yes If you answered "YES" to A, B, C, D, or E above: i. Name all persons