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: CO - 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. $ 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: 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 1. CHILDREN A. *List all JOINT CHILDREN (children under the age of 21 born or adopted during this relationship): Children Living With: Over 18 & Under 21 Attending School Name of Child Age Me Other Parent Other 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 Gross hourly wage. 2 Average number of hours worked per pay period. x 3 x 4 Convert to monthly. 367 12 5 Gross monthly income: 1. x 2. x 3. 367 4. 6 Gross monthly tips/commissions/bonuses (identify): Subtotal of Monthly Income From Employment (5) + (6) SUBTOTAL: 2.A. 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 Monthly Amount Self - Employment Dividends Interest Income Trust Income Annuity Income Social Security Income 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 TOTAL: C. *Do you receive Temporary Assistance for Needy Families? Yes, $ monthly No D. any joint child(ren) due to disability? Name of Beneficiary Child(ren) Yes, $ monthly No Name of Disabled Parent Source E. any joint child(ren) due to 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 No H. *Are you ordered to PAY spousal support? Yes, $ monthly No 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. 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? 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 No ii. Receiving a state subsidy for public or private health care coverage? Yes 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 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 $. v. Policy Number: Group Number: vi. Address for submission of claims: vii. Your total monthly premium cost: (A)$; 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) 367 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 No If yes, who? ; amount they pay? $ H. ATTACH PROOF OF MONTHLY MEDICAL EXPENSES. Page 4 - 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 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)? Yes No If yes, name: 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://oregonchildsupport.gov/laws/rules/docs/0500760.pdf i. Are you seeking a rebuttal (an adjustment to the support amount)? Yes No ii. Explain briefly: 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. DATED this day of , 20 . My (printed) Name Is I am: PETITIONER RESPONDENT CO-PETITIONER OTHER: SIGNATURE Page 5 - FORM 8.010.5 UNIFORM SUPPORT DECLARATION OF PETITIONER RESPO