Free Declaration of Income and Expenses - Utah

_________________________________ Name _________________________________ Address _________________________________ City _________________________________ Telephone ______________________________________________________________________________ IN THE_________________DISTRICT JUVENILE COURT FOR ____________________COUNTY ______________________________________________________________________________ IN THE INTEREST OF_________________, ) DECLARATION OF INCOME A MINOR. ) AND EXPENSES ) JUVENILE NO.__________________ ) ) ______________________________________________________________________________ I solemnly swear or affirm that the following is true: Income:
I was born on: 9 I have the following job(s). My employer's name and address is: Monthly pay before deductions: $_______________ (If you do not have a job, write "None" in this space) 9 I have income from sources other than employment. Include such sources as rental income, money or other support. Source of Income Monthly income, non-wage $_______________ Monthly pay after deductions: $_______________

May 6, 2006

9 I receive this much per month from government programs. (Include such sources as social security benefits, worker's compensation, housing, food, other living allowances, etc.) 9 I share a household with others, some of whom have jobs and share the cost of household expenses. The names of these household members are listed in this box: Name:________________________ Name:________________________ Assets:

Source of Income

Monthly income from government programs $_______________

Monthly pay, before deductions, of others in household: $_________________ $_________________

Monthly pay after deductions of others in household: $_______________ $_______________

9 I have this much money in cash, in the bank, in stocks or bonds, and in other available sources: 9 Other people or organizations owe me this much money:

$____________ $____________

9 I own or am buying a home, land, other real property, vehicles, other personal property, or business interests as listed below. Property (home, land, vehicles, etc.) and location Home Land and other real property Cars, trucks, or other vehicles Other personal property Business interests Balance owed Value $_______________ $_______________ $_______________ $_______________ $_______________

May 6, 2006

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Debt: 9 I owe the following debts: To whom owed Amount $________________ $________________ $________________ Expenses: 9 In an average month, I spend money for the following items: Amount Food Clothing Cost of housing Transportation $__________ $__________ $__________ $__________ Gas Water Telephone Uninsured medical expenses Health insurance Amount $__________ $__________ $__________ $__________ Education expense Other (list) $__________ $__________ Child support Amount $__________ To whom owed Amount $_______________ $_______________ $_______________

Electricity

$__________

$__________

Other (list)

$__________

Being sworn, I affirm that: · I have read this Declaration of Income and Expenses and the statements in it are true and correct to the best of my knowledge. I know that an intentionally false statement could subject me to prosecution for perjury. _____________________________ Petitioner

·

May 6, 2006

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Notary Clause _______________________________, Petitioner, is personally known to me or presented satisfactory proof of identity to me. After being sworn and while under oath, Petitioner stated that he or she was acting voluntarily, had read and understood the preceding document, and that the contents were true. Petitioner then signed the document in my presence. Signed on__________________________, 20_____. X____________________________________ Notary Public/ Court Clerk (Notary Seal)

May 6, 2006

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