Uniform Support Declaration Page 1 of 2 (Aug 2019) IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF Case No: Petitioner and UNIFORM SUPPORT DECLARATION Respondent CSP No.: Unmarried children age 18, 19, or 20 years old (per ORS 107.108) I am the petitioner respondent other: 1. Number of children a. Joint minor children (children of the parties together) b. Joint adult children (age 18, 19, or 20) i. Joint adult children attending school unknown c. Non-joint minor children (children of only one party) Number of overnights the joint children spend with me (per year) i. Current order, judgment, or written agreement ii. Proposed 2. Sources of income Wages/Salary: (monthly, before taxes) $ per hour hours/week Subtotal A : $ (Complete table below with monthly averages, before taxes. Explain 223other224 amounts) Tips: Bonuses/Commission: Workers Comp: Interest: Social Security: Annuity: Unemployment: Trust: Disability: Dividends: TANF: Other: Other: Other: Other: Other: Expense reimbursement/per diem allowance that reduces personal living expenses: Subtotal B: $ Gross monthly income TOTAL (add Subtotal A + B) $ 3. Spousal/partner support a. Received by me (from anyone) $ b. Paid by me (to anyone) $ 4. Health insurance a. Premium to cover just me $ American LegalNet, Inc. www.FormsWorkFlow.com Uniform Support Declaration Page 2 of 2 (Aug 2019) b. Premium paid for joint children $ c. Out of pocket medical costs paid for joint children $ d. Subsidies received for health insurance costs $ e. Oregon Health Plan (or other public health insurance) yes no 5. Other a. Union dues $ b. Social Security or Veteran222s Benefits received for children $ i. Person with disability is: child me other parent c. Childcare expenses for joint children (12 or younger) $ i. City or ZIP where child care is provided: ii. Does anyone else share the cost of childcare? yes no 1. Name: Amount: $ 6. Rebuttal factors (The amount of child support is based on statewide guidelines. The guideline amount can be rebutted (challenged) under OAR 137-050-0760, click here to read the rule: https://www.doj.state.or.us/wp-content/uploads/2017/08/0500760.pdf ) I am challenging the guideline amount (explain rebuttal factors): Attachments 4 most recent pay stubs Benefit statements Most recent tax return Copies of currently effective spousal/partner support, child support, and parenting time orders or judgments Proof of health insurance premiums and any subsidies received Proof of out of pocket medical expenses Proof of childcare expenses Evidence supporting any rebuttal factors for child support I hereby declare that the above statements are true to the best of my knowledge and belief. I understand they are made for use as evidence in court. I understand I am subject to penalty for perjury. Date Signature Name (printed) Contact Address City, State, ZIP Contact Phone American LegalNet, Inc. www.FormsWorkFlow.com Uniform Support Declaration 226 Certificate of Mailing Page 1 of 1 (Aug 2019) (Serve the other party and all adult children who have not filed a Waiver of Further Appearance) Certificate of Mailing I certify that on (date): I placed a true and complete copy of this Declaration and Attachment (if necessary) in the United States mail to (name): at (address): Date Signature Name (printed) American LegalNet, Inc. www.FormsWorkFlow.com Uniform Support Declaration - Attachment Page 1 of 2 (Aug 2019) Uniform Support Declaration Attachment You must complete this attachment if either party seeks: spousal/partner support OR deviation from the child support guidelines These are the total household expenses you must pay each month for yourself only - not for others in your household. Any other annual, quarterly, or other periodic payments should be converted to a monthly average. DO NOT LIST ANY EXPENSE IF IT IS DEDUCTED FROM YOUR WAGES 1. FIXED COSTS: Description Monthly Amount A. RESIDENCE: Mortgage or Rent Second Mortgage/Home Equity Loan Property Taxes and Insurance (if not included in mortgage) B. UTILITIES: (averaged over the year) Electricity Gas Water/Sewer Trash/Recycling Telephone/Cell Phone Cable/Internet C. TRANSPORTATION: Car Payments Fuel Bus pass/Van pool/Etc. Other (specify): D. INSURANCE: Life Automobile Medical/Dental Other (specify): E. Food and Household Items F. U nreimbursed health costs , including medications G. Court/Agency - o rdered Support Payments in other case s TOTAL FIXED COSTS: American LegalNet, Inc. www.FormsWorkFlow.com Uniform Support Declaration - Attachment Page 2 of 2 (Aug 2019) 2. DEBTS: Name of Creditor (who debt is owed to) Balance Due Monthly Payment TOTAL MONTHLY DEBT PAYMENTS: Additional page attached 3. Total Fixed Costs + Monthly Debts = $ 4. Other factors you want the court to consider: American LegalNet, Inc. www.FormsWorkFlow.com