Free Uniform Support Affidavit - Oregon

IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF LINN

In the Matter of the Dissolution of Marriage/Separation of::

____________________________________________, Petitioner,

AND ____________________________________________, Respondent

) ) ) ) ) ) ) ) ) ) )

Circuit Court No._________________________ Uniform Support Affidavit of: Petitioner Respondent (Child/Spousal Support Case)

This form is a SWORN AFFIDAVIT (under oath) required for support determinations. It must be signed before a notary public, may be made available to the other party, and may be filed in court. The form consists of this part, on pages 1 through 6, and any attachments requested on those pages. If either party seeks spousal support or any change from the uniform child support guidelines, you must also complete the following and the attachments requested therein and submit all of them with this form: 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 ________________________) I, _______________________, being first duly sworn under oath, depose and say that I am the_________________in the above-entitled matter and that the following are true to the best of my knowledge and belief: Petitioner/Respondent 1. 2. 3. 4. 5. 6. /// /// Your Age: Date of Birth: Residence Address: Name of Employer &Address: Occupation: Length of Employment: Children born of or adopted during this relationship: Social Security Number: File under UTCR 2.100

Title:

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Petitioner Respondent

Child living with: Name of Child Age Me Other Parent Other

7.

List all people living in your household (other than children named in item 6 above): Name Age Relationship to You Monthly Income

8.

List your other dependents or children not listed in items 6 or 7 above: Name Age Relationship to You Monthly Income

9.

ENTER THE FOLLOWING INFORMATION FROM SCHEDULES INDICATED: A. TOTAL GROSS INCOME (From page 4, item 16.D.) B. TOTAL EXPENSES OF CHILDREN (From Schedule 1, item 1.) C. TOTAL MONTHLY EXPENSES (From Schedule 1, item 6.) : : :

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 Age Relation to You Support Amount ____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ (b) Are those support payments being made? YES NO
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Petitioner Respondent

11.

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 CHILD SUPPORT ORDERS.

Name of Child Age Name of Recipient Monthly Support Amount _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 12. 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 Monthly Support Amount _____________________________________________________________________________________________________ Owed Until:______________________________(Date or Event):________________________________________________ 13. 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 Day-care Provider Monthly (gross amount before application child and Address cost of any tax credit or subsidy) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 14. 15. Do you receive any subsidy for such care? If so, amount $_________________per month. 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 5, item 18, of this schedule, for information.
ATTACHMENTS REQUIRED OPTIONAL

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.

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Petitioner Respondent

(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 profits and loss statement. 16. Your Monthly gross Income: A. From Employment: If paid weekly, multiply weekly income be 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: Description Gross Hourly Wage:_________________________________ Average Number of Hours Worked Per Week:____________ Gross Monthly Income: Gross Monthly Tips/Commissions/Bonuses (identify): SUBTOTAL 16.A. Monthly Amount

_____________________________ _____________________________ _____________________________

B. From Self-Employment: If you own an interest in partnership or in a closely held corporation, attach last year's schedule K-1 and/or corporation federal income tax return: 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: Monthly Amount ______________________ _______ _____________________________ _____________________________ _____________________________ (____________________________)

_____________________________ SUBTOTAL 16.B. C. _____________________________

Other Sources of Income: (Please attach verification of any income available to you as listed below): 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: Monthly Amount _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________per month _____________________per month _____________________________ _____________________________ _____________________________ _____________________________ _____________________________

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Petitioner Respondent

FCAS (food stamps): Other (specify): __________________________ SUBTOTAL 16.C. D: Summary of Your Gross Income: Description Income from Employment (item 16.A. above) Self-Employed Income (item 16.B. above) Other Income (item 16.C. above)

_____________________________ _____________________________ _____________________________

Monthly Amount _____________________________ _____________________________ _____________________________ _____________________________

YOUR TOTAL MONTHLY GROSS INCOME: ENTER HERE and on this Affidavit Page 2, line 9.A. 16.D. _____________________________ 17. Your Monthly Deductions from Gross Income: A. Mandatory Deductions: Number or 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 Total Premium_____________­ less cost of coverage for yourself + other dependants = SUBTOTAL OF MANDATORY: B. Optional Deductions: Description Retirement/Profit Sharing: Savings Plan: Credit Union: Other: SUBTOTAL OF OPTIONAL: Monthly Amount _____________________________ _____________________________ _____________________________ _____________________________ 17.B. _____________________________ Monthly Amount _____________________________ _____________________________ _____________________________ _____________________________ _____________________________

_____________________________ 17.A. _____________________________

C. Summary or Deductions: Mandatory--from item 17.A. above: ____________________ Optional--from item 17.B. above: ______________________ TOTAL MONTHLY DEDUCTIONS 17.C. _____________________________
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Petitioner Respondent

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) 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:

HEALTH INSURANCE

DENTAL INSURANCE

____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________

____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________

Are there dependents other than children on page 1, item 6, of this Affidavit enrolled with plan? YES NO If Yes, total number or other dependants: ____________________ ____________________

Certificate of Document Preparation. You are required to truthfully complete this certificate regarding the document you are filing with the court. Check all boxes and complete all blanks that apply: I selected this document for myself and I completed it without paid assistance. I paid or will pay money to for assistance in preparing this form. I certify that my answers and this information on this affidavit and the attached schedules are true to the best of my knowledge and ability. I further certify that the information on the attached documents is true to the best of my knowledge and ability. Dated this _____ day of ____________________________, 20____. ________________________________________________ Signature ________________________________________________ Print Name

SUBSCRIBED AND SWORN TO BEFORE ME THIS______ DAY OF__________________________, 20_______.

________________________________________________ Notary Public for Oregon My Commission Expires:____________________________

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Petitioner Respondent

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 DEDUCED FROM YOU 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. School Expenses: School Lunches: Books, Tuition: Activities: Other (Specify): B. Food (Other than school lunches): C. Day Care: D. Clothing: E. Medical Insurance--Premium Payments: F. Unreimbursed Health Costs: G. Unreimbursed Dental Costs: H. Baby--Sitting (not work-related): I. Lessons: J. Grooming Needs: K. Hobbies, Recreation: L. Entertainment: M. Allowances: N. Transportation: Gasoline, Oil: Insurance for Driving-Age Child: O. Miscellaneous (Specify):_____________________________ _____________________________________________________ TOTAL DIRECT EXPENSES OF CHILDREN: (Add 1.A. thru 1.O.): ENTER HERE and on Uniform Support Affidavit page 2. Line 9.B. _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________

1. _______________________

Average Monthly Amount of Child's Income:

Source Amount Name _______________________________________________________ _______________________________________________________ Monthly Amount ___________________ ___________________ ___________________ ___________________

2.

FIXED COSTS A. RESIDENCE: Mortgage or Rent: Property Taxes: (If not included in mortgage) Second Mortgage: Other:

Page 1 of 3, Schedule 1, UNIFORM SUPPORT AFFIDAVIT of Petitioner Respondent
Uniform Support Affidavit 3-04.wpd (12/03)

B. UTILITIES: Electricity: Heat (other than electricity): Water: Garbage: Telephone: Other: C. TRANSPORTATION: Car Payments: Gas &Oil: Maintenance & Repairs: Other (Specify): D. INSURANCE: Life: Automobile: Medical/Dental: Residence: E. FOOD AND HOUSEHOLD ITEMS: (exclude food expenses for joint children covered in Schedule 1, part 1, above) F. CLOTHING: Grooming/Personal Needs:

____________________ ____________________ ____________________ ____________________ ____________________ ____________________

____________________ ____________________ ____________________ ____________________

____________________ ____________________ ____________________ ____________________ ____________________

____________________ ____________________ ________________ ________________ 2. ________________

G. MEDICINE AND PHARMACEUTICAL--Unreimbursed medical/dental costs: H. COURT/DHR-ORDERED SUPPORT PAYMENTS: TOTAL FIXED COSTS (A-H): 3. CONSUMER OBLIGATIONS: NAME OF CREDITORS _________________________________ _________________________________ _________________________________ _________________________________ BALANCE DUE ______________ ______________ ______________ ______________

MONTHLY PAYMENTS _____________________ _____________________ _____________________ _____________________ 3. _____________________

TOTAL MONTHLY PAYMENTS ON CONSUMER OBLIGATIONS: 4. DISCRETIONARY EXPENSES: A. B. C. D. Entertainment: Vacations: Gifts: Religious Contributions: ____________________ ____________________ ____________________ ____________________

Page 2 of 3, Schedule 1, UNIFORM SUPPORT AFFIDAVIT of Petitioner Respondent Co-Petitioner
Uniform Support Affidavit 3-04.wpd (12/03)

E. Dues and Subscriptions: F. Club Memberships & Dues: TOTAL DISCRETIONARY EXPENSES: 5. ADDITIONAL EXPENSES: _______________________________ _______________________________

____________________ ____________________ 4. _____________________

____________________ ____________________ 5. ______________________

TOTAL ADDITIONAL EXPENSES: 6. TOTAL EXPENSES EXCLUDING DIRECT EXPENSES OF CHILD (Add 2, 3, 4 and 5): ENTER HERE and on Uniform Support Affidavit, page 2, line 9C.

6. _______________________

7.

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 3 of 3, Schedule 1, UNIFORM SUPPORT AFFIDAVIT of Petitioner Respondent
Uniform Support Affidavit 3-04.wpd (12/03)