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? Yes No 6. Child(ren) on Oregon Health Plan/Healthy Kids or Other Public Health Plan? Yes No 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 Only if You Provide Insurance for Child(ren): $_______________ 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: _______________ $_______________ ____________________________________________ Page 1 - FORM 8.010.5 – UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G CO-PETITIONER G CO-RESPONDENT G OTHER G – UTCR 8.010(5), 8.010(8), 8.040(3), 8.040(4), 8.050(1), 8.050(3) (Revised 8-1-10) UTCR App. Page 33 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 2. Age YOUR GROSS INCOME A. From Your Employment: Description Monthly Amount 1 Gross hourly wage. 2 Average number of hours worked per pay period. x 3 Convert to annual. If paid monthly, enter “12”. If paid twice monthly, enter “24”. Every two weeks, enter “26”. Every week, enter “52”. x 4 Convert to monthly. ÷ 5 Gross monthly income: 1. x 2. x 3. ÷ 4. 6 Gross monthly tips/commissions/bonuses (identify): Subtotal of Monthly Income From Employment (5) + (6) 12 SUBTOTAL: 2.A. Page 2 - FORM 8.010.5 – UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G CO-PETITIONER G CO-RESPONDENT G OTHER G – UTCR 8.010(5), 8.010(8), 8.040(3), 8.040(4), 8.050(1), 8.050(3) (Revised 8-1-10) UTCR App. Page 34 American LegalNet, Inc. www.FormsWorkFlow.com B. Other Sources of Your Monthly Income: (Attach verification of your gross monthly income as listed below): Description Monthly Amount 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 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 No 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 No 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 No 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? No Yes, $________ monthly No Yes, $________ monthly No If Yes, to whom? __________________________________ I. *Do you pay mandatory union dues? 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. Page 3 - FORM 8.010.5 – UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G CO-PETITIONER G CO-RESPONDENT G OTHER G – UTCR 8.010(5), 8.010(8), 8.040(3), 8.040(4), 8.050(1), 8.050(3) (Revised 8-1-10) UTCR App. Page 35 American LegalNet, Inc. www.FormsWorkFlow.com 3. HEALTH CARE COVERAGE AND MEDICAL EXPENSES A. *Is there a cost to insure just yourself if you provide insurance for the child(ren)? Yes No B. Do you provide health care coverage for your joint child(ren)? Yes No C. Does someone else provide health care coverage for your joint child(ren)? Yes No Name of person, or entity, providing, if other than you: D. Are you or any member of your household: i. Enrolled in the Oregon Health Plan, Healthy Kids, or any other public health care coverage? Yes ii. Yes Receiving a state subsidy for public or private health care coverage? 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 No If you answered “YES” to A, B, C, D, or E above: i. Name all persons covered: Relationship to you: ii. What is the source of the insurance? (such as through your employer, spouse, other): iii. Insurance Co.: Phone Number: iv. Monthly amount of any state subsidy received by your household for public or private health-care coverage $____________. Group Number: v. Policy Number: vi. Address for submission of claims: vii. Your total monthly premium cost: (A)$____________; Cost to cover only you: (B)*$____________; Total number of people enrolled (not counting yourself): (C)$____________; Number of joint children enrolled: (D)______ *The cost for the joint child(ren) only is (A – B) ÷ C = $____________ x D = *$____________ viii. ATTACH PROOF OF INSURANCE PREMIUMS. F. *Do you pay any out-of-pocket medical expenses (not covered by insurance) for any joint child(ren) on a monthly basis? Yes No If yes, list the name of the child, the reason for the cost(s), and the amount per month: i. ;$ ii. ;$ iii. ;$ iv. ;$ G. Does anyone pay a share of the monthly out-of-pocket medical costs for the child(ren)? Yes ; amount they pay? $ If yes, who? H. ATTACH PROOF OF MONTHLY MEDICAL EXPENSES. Page 4 - FORM 8.010.5 – UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G CO-PETITIONER G CO-RESPONDENT G OTHER G – UTCR 8.010(5), 8.010(8), 8.040(3), 8.040(4), 8.050(1), 8.050(3) (Revised 8-1-10) UTCR App. Page 36 American LegalNet, Inc. www.FormsWorkFlow.com No 4. YOUR CHILDCARE EXPENSES A. *Do you pay for childcare for the joint child(ren) so you can work, train, or look for work? Yes No If yes,: Paid to: Name of Child Age Average Monthly Payment B. *Does anyone else share the cost of childcare for the joint child(ren)? If yes, name: Yes No Average Monthly Amount $ C. *City where childcare is provided: D. ATTACH COPIES OF PROOF OF CHILDCARE EXPENSES. 5. *YOUR PARENTING TIME PROPOSED OCCURRING EXISTING PLAN OR WRITTEN AGREEMENT A. How many ANNUAL overnights does each joint child spend with YOU? i. Name of Child: ___________________________________ # of overnights: _______________ ii. Name of Child: ___________________________________ # of overnights: _______________ iii. Name of Child: ___________________________________ # of overnights: _______________ iv. Name of Child: ___________________________________ # of overnights: _______________ B. ATTACH COPY OF MOST RECENT PARENTING PLAN OR WRITTEN AGREEMENT. 6. YOUR REBUTTAL FACTORS A. The amount of child support to be paid may be rebutted under OAR 137-050-0760. http://www.dcs.state.or.us/oregon_admin_rules/default.htm i. Are you seeking a rebuttal (an adjustment to the support amount)? ii. Explain briefly: Yes No B. ATTACH SUPPORTING EVIDENCE/ADDITIONAL INFORMATION. I HEREBY DECLARE THAT THE ABOVE STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND THAT I UNDERSTAND THEY ARE MADE FOR USE AS EVIDENCE IN COURT AND ARE SUBJECT TO PENALTY FOR PERJURY. day of DATED this My (printed) Name Is I am: PETITIONER RESPONDENT OTHER: , 20 . CO-PETITIONER SIGNATURE Page 5 - FORM 8.010.5 – UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G CO-PETITIONER G CO-RESPONDENT G OTHER G – UTCR 8.010(5), 8.010(8), 8.040(3), 8.040(4), 8.050(1), 8.050(3) (Revised 8-1-10) UTCR App. Page 37 American LegalNet, Inc. www.FormsWorkFlow.com ATTACHMENT CHECKLIST. Check the box and include the appropriate attachment(s). Four most recent pay stubs or benefit statements Most recent state and federal tax returns (including all applicable schedules) Proof of insurance premiums Proof of medical costs Most recent parenting plan or written agreement Proof of childcare costs Copies of Spousal and Child Support Orders Additional Page: Number items to correspond, include your name and case number Other: _________________________________ CERTIFICATE OF MAILING I hereby certify that I served a true and complete copy of this Uniform Support Declaration and all attachments by mailing it first class mail, with postage prepaid, on to the following people: (date) (Other Party/Attorney name) 1. Address: 2. (name) Address: SIGNATURE Page 6 - FORM 8.010.5 – UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G CO-PETITIONER G CO-RESPONDENT G OTHER G – UTCR 8.010(5), 8.010(8), 8.040(3), 8.040(4), 8.050(1), 8.050(3) (Revised 8-1-10) UTCR App. Page 38 American LegalNet, Inc. www.FormsWorkFlow.com SCHEDULE 1 Spousal/Registered Domestic Partner Support Factors You must complete this schedule and prepare and submit the attachments requested in this schedule if either party seeks spousal support. These are the total household expenses you must pay each month for yourself only and not for others in your household. 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. 1. A. B. C. D. E. F. G. FIXED COSTS: Description RESIDENCE: Mortgage or Rent Second Mortgage/Home Equity Loan Property Taxes (if not included in Mortgage) Insurance (if not included in Mortgage) UTILITIES: Electricity Gas Water Garbage Telephone Cable/Internet TRANSPORTATION: Car Payments Fuel Maintenance and Repairs Other (specify): INSURANCE: Life Automobile Medical/Dental Other (specify): Food and Household Items Medicine &Pharmaceutical – unreimbursed medical/dental costs Court/DHR-Ordered Support Payments for other than child(ren)/spouse/RDP in this case TOTAL FIXED COSTS (A-G): Monthly Amount Page 7 - FORM 8.010.5 – UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G CO-PETITIONER G CO-RESPONDENT G OTHER G – UTCR 8.010(5), 8.010(8), 8.040(3), 8.040(4), 8.050(1), 8.050(3) (Revised 8-1-10) UTCR App. Page 39 American LegalNet, Inc. www.FormsWorkFlow.com 2. CONSUMER OBLIGATIONS: Balance Due Name of Creditor Monthly Amount A. B. C. D. E. F. TOTAL PAYMENTS ON CONSUMER OBLIGATIONS (A-F): 3. SUMMARY OF EXPENSES: Description Monthly Amount Fixed Costs (item 1 above) Consumer Obligations (item 2 above) TOTAL EXPENSES: 4. OTHER FACTORS: Other factors that affect my income and expense or that should be considered (attach supporting documentation whenever possible). TOTAL: My (printed) Name is: I am: PETITIONER RESPONDENT CO-PETITIONER OTHER: Page 8 - FORM 8.010.5 – UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G CO-PETITIONER G CO-RESPONDENT G OTHER G – UTCR 8.010(5), 8.010(8), 8.040(3), 8.040(4), 8.050(1), 8.050(3) (Revised 8-1-10) UTCR App. Page 40 American LegalNet, Inc. www.FormsWorkFlow.com