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Uniform Support Affidavit Of Petitioner Respondent Co-Petitioner (Child-Spousal Support Case) Form. This is a Oregon form and can be use in Uniform Trial Court Statewide.
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Tags: Uniform Support Affidavit Of Petitioner Respondent Co-Petitioner (Child-Spousal Support Case), 8.010.5, Oregon Statewide, Uniform Trial Court
IN THE CIRCUIT COURT OF THE STATE OF OREGON
FOR THE COUNTY OF
In the Matter of:
)
)
)
,
Petitioner,
Circuit Court No.
)
)
)
)
)
)
AND
,
Respondent.
Uniform Support Affidavit of:
“ Petitioner
“ Respondent “ Co-petitioner
(Child or Spousal Support Case)
This form is an AFFIDAVIT (under penalty of perjury) required for support determinations. It must be signed, 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, certain documentation MUST be attached as indicated on
page 2.
STATE OF OREGON
)
) ss.
)
County of
, being first duly sworn under oath, depose and say that I am the
I,
and that the following are true to the best of my knowledge and belief:
1.
2.
3.
4.
5.
6.
Date of Birth:
Your Age:
Residence Address:
Name of Employer & Address:
Occupation:
Length of Employment:
Children born of or adopted during this relationship:
in the above-entitled matter
Social Security No.: File under UTCR 2.100
Title:
Child living with:
Name of Child
7.
Other Parent
Other
Age
Relationship to You
Monthly Income
Relationship to You
Monthly Income
List your other dependents or children not listed in items 6 or 7 above:
Name
9.
Me
List all people living in your household (other than children named in item 6 above):
Name
8.
Age
Age
ENTER THE FOLLOWING INFORMATION FROM SCHEDULES INDICATED:
A. TOTAL GROSS INCOME (From page 3, item 16.D.)
:
B. TOTAL EXPENSES OF CHILDREN (From Schedule 1, item 1.) :
C. TOTAL MONTHLY EXPENSES (From Schedule 1, item 6.) :
Page 1 - FORM 8.010.5 – Uniform Support Affidavit of Petitioner “ Respondent “ Co-petitioner “ – UTCR 8.010(5), 8.010(7), 8.040(3), 8.040(4),
8.050(1), 8.050(3)
(Revised 8-1-05)
UTCR App. Page 14
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www.USCourtForms.com
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
(b)
11.
Age
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 SUCH CHILD SUPPORT ORDERS.
Age
Name of Recipient
Monthly Support Amount
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
Owed Until:
13.
Support Amount
Are those support payments being made? YES “ NO “
Name of Child
12.
Relation to You
Monthly Support Amount
(Date or Event):
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
Child
Day-care Provider
and Address
Monthly (gross amount before application
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's(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 4, item 18, of this schedule, for information.
ATTACHMENTS
OPTIONAL
REQUIRED
“
Last four (4) payroll stubs.
“
Most recent federal and state income tax return.
“
Copies of any and all relevant child/spousal support orders.
“
“
Child care documentation if you want this considered.
Medical/dental insurance documentation.
Page 2 - FORM 8.010.5 – Uniform Support Affidavit of Petitioner “ Respondent “ Co-petitioner “ – UTCR 8.010(5), 8.010(7), 8.040(3), 8.040(4),
8.050(1), 8.050(3)
(Revised 8-1-05)
UTCR App. Page 15
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(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 profit 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):
Monthly Amount
Description
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 a partnership or in a closely held corporation, attach last year's Schedule K-1, and/or
corporation federal income tax return:
Monthly Amount
Description
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.
Other Sources of Income: (Please attach verification of any income available to you as listed below):
Monthly Amount
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 =
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):
per month
per month
SUBTOTAL: 16.C.
D.
Summary of Your Gross Income:
Monthly Amount
Description
Income from Employment (item 16.A. above):
Self-Employment Income (item 16.B. above):
Other Income (item 16.C. above):
YOUR TOTAL MONTHLY GROSS INCOME:
ENTER HERE and on this
Affidavit Page 1, line 9.A.
16.D.
Page 3 - FORM 8.010.5 – Uniform Support Affidavit of Petitioner “ Respondent “ Co-petitioner “ – UTCR 8.010(5), 8.010(7), 8.040(3), 8.040(4),
8.050(1), 8.050(3)
(Revised 8-1-05)
UTCR App. Page 16
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17.
Your Monthly Deductions from Gross Income:
A.
Mandatory Deductions:
Number of exemptions claimed by you:
Description
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
--less cost of coverage for yourself +
Total Premium
other dependents =
Monthly Amount
)
SUBTOTAL OF MANDATORY:
B.
17.A.
Optional Deductions:
Monthly Amount
Description
Retirement/Profit Sharing:
Savings Plan:
Credit Union:
Other:
SUBTOTAL OF OPTIONAL:
C.
17.B.
Summary of Deductions:
Mandatory--from item 17.A. above:
Optional--from item 17.B. above:
TOTAL MONTHLY DEDUCTIONS: 17.C.
18.
Information for Medical and Dental Insurance Coverage: (For children listed on page 1, 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
DENTAL 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:
*
*
*
*
*
*
*
*
*
*
Are there dependents other than children on page 1,
item 6, of this Affidavit enrolled with plan? YES “ NO “
If Yes, total number of other dependents:
*
I hereby declare that the above statement and the attached schedules are true to the best of my knowledge and belief, and that I understand it is made for
use as evidence in court and is subject to penalty for perjury.
DATED this __________ day of _________________________, 20____.
_____________________________________________________________
Name
Page 4 - FORM 8.010.5 – Uniform Support Affidavit of Petitioner “ Respondent “ Co-petitioner “ – UTCR 8.010(5), 8.010(7), 8.040(3), 8.040(4),
8.050(1), 8.050(3)
(Revised 8-1-05)
UTCR App. Page 17
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www.USCourtForms.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
DEDUCTED 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.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
School Expenses:
School Lunches:
Books, Tuition:
Activities:
Other (Specify):
Food (other than school lunches):
Day Care:
Clothing:
Medical Insurance--Premium Payments:
Unreimbursed Health Costs:
Unreimbursed Dental Costs:
Baby-Sitting (not work-related):
Lessons:
Grooming Needs:
Hobbies, Recreation:
Entertainment:
Allowances:
Transportation:
Gasoline, Oil:
Insurance for Driving-Age Child:
Miscellaneous (Specify):
TOTAL DIRECT EXPENSES OF CHILDREN:
(ADD 1.A. thru 1.O.)
ENTER HERE and on Uniform Support
Affidavit page 1, 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.
Monthly Amount
INSURANCE:
Life:
Automobile:
Medical/Dental:
Residence:
E.
Name
*
*
TRANSPORTATION:
Car Payments:
Gas & Oil:
Maintenance & Repairs:
Other (Specify):
D.
Amount
*
*
UTILITIES:
Electricity:
Heat (other than electricity):
Water:
Garbage:
Telephone:
Other:
C.
1.
FOOD AND HOUSEHOLD ITEMS:
(exclude food expenses for
joint children covered in
Schedule 1, part 1, above)
Page 5 - FORM 8.010.5 – Uniform Support Affidavit of Petitioner “ Respondent “ Co-petitioner “ – UTCR 8.010(5), 8.010(7), 8.040(3), 8.040(4),
8.050(1), 8.050(3)
(Revised 8-1-05)
UTCR App. Page 18
American LegalNet, Inc.
www.USCourtForms.com
F.
CLOTHING:
Grooming/Personal Needs:
G.
MEDICINE AND PHARMACEUTICAL--Unreimbursed medical/dental costs:
H.
COURT/DCS-ORDERED SUPPORT PAYMENTS:
TOTAL FIXED COSTS (A-H):
3.
2.
CONSUMER OBLIGATIONS:
NAME OF CREDITOR
BALANCE DUE
MONTHLY PAYMENTS
TOTAL MONTHLY PAYMENTS ON CONSUMER OBLIGATIONS: 3.
4.
DISCRETIONARY EXPENSES:
A.
B.
C.
D.
E.
F.
Entertainment:
Vacations:
Gifts:
Religious Contributions:
Dues and Subscriptions:
Club Memberships & Dues:
TOTAL DISCRETIONARY EXPENSES:
TOTAL ADDITIONAL EXPENSES:
5.
6.
7.
4.
5.
ADDITIONAL EXPENSES:
TOTAL EXPENSES EXCLUDING DIRECT EXPENSES OF CHILD
(Add 2, 3, 4, and 5): ENTER HERE and on Uniform Support Affidavit,
page 1, line 9.C.
6.
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).
Page 6 - FORM 8.010.5 – Uniform Support Affidavit of Petitioner “ Respondent “ Co-petitioner “ – UTCR 8.010(5), 8.010(7), 8.040(3), 8.040(4),
8.050(1), 8.050(3)
(Revised 8-1-05)
UTCR App. Page 19
American LegalNet, Inc.
www.USCourtForms.com
