Free Form 8.010.5 - Oregon

IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF In the Matter of: , Petitioner, AND , Respondent. ) ) ) ) ) ) ) ) )

Circuit Court No. Uniform Support Affidavit of: G Petitioner G Respondent G 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 County of ) ) ss. ) in the above-entitled

I, , being first duly sworn under oath, depose and say that I am the matter and that the following are true to the best of my knowledge and belief: 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 No.: File under UTCR 2.100 Title:

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 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 G Respondent G Co-petitioner G ­ 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 22

10.

(a)

Are you or your present spouse entitled to receive court-ordered child support for any children now living with you? YES G NO G If "YES," complete the following and ATTACH A COPY OF ALL SUCH CHILD SUPPORT ORDERS. Age Relation to You Support Amount

Name of Child

(b) 11.

Are those support payments being made? YES G NO G

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 G NO G If "YES," complete the following and ATTACH A COPY OF ALL SUCH CHILD SUPPORT ORDERS. Age Name of Recipient Monthly Support Amount

Name of Child

12.

Are you ordered to pay or entitled to receive court-ordered spousal support? YES G NO G If "YES," complete the following and ATTACH A COPY OF ALL SUCH SPOUSAL SUPPORT ORDERS. Paid By (Date or Event): Monthly Support Amount

Owed To Owed Until: 13.

Are you incurring child care costs on behalf of the children listed in item 6 above? YES G NO G If "YES," complete the following and attach documentation verifying the information provided below: Day-care Provider and Address Monthly (gross amount before application Cost of any tax credit or subsidy)

Name of Child

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: G G G 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 REQUIRED G G G Last four (4) payroll stubs. Most recent federal and state income tax return. Copies of any and all relevant child/spousal support orders. G G OPTIONAL Child care documentation if you want this considered. Medical/dental insurance documentation.

Page 2 - FORM 8.010.5 ­ Uniform Support Affidavit of Petitioner G Respondent G Co-petitioner G ­ 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 23

(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): 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: 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): 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): SUBTOTAL: 16.C. D. Summary of Your Gross Income: 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. Monthly Amount Monthly Amount Monthly Amount Monthly Amount

(

)

per month per month

16.D.

Page 3 - FORM 8.010.5 ­ Uniform Support Affidavit of Petitioner G Respondent G Co-petitioner G ­ 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 24

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 Total Premium --less cost of coverage for yourself + other dependents = Monthly Amount

)

SUBTOTAL OF MANDATORY: B. Optional Deductions: Description Retirement/Profit Sharing: Savings Plan: Credit Union: Other: SUBTOTAL OF OPTIONAL: C. Summary of Deductions: Mandatory--from item 17.A. above: Optional--from item 17.B. above:

17.A.

Monthly Amount

17.B.

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.): G I provide this (complete information below) G 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 G NO G If Yes, total number of other dependents: HEALTH INSURANCE DENTAL INSURANCE



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 G Respondent G Co-petitioner G ­ 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 25

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

B. C. D. E. F. G. H. I. J. K. L. M. N. O.

TOTAL DIRECT EXPENSES OF CHILDREN: (ADD 1.A. thru 1.O.)

1. Name

C.

D.

E.

Page 5 - FORM 8.010.5 ­ Uniform Support Affidavit of Petitioner G Respondent G Co-petitioner G ­ 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 26

F. G. H.

CLOTHING: Grooming/Personal Needs: MEDICINE AND PHARMACEUTICAL--Unreimbursed medical/dental costs: COURT/DCS-ORDERED SUPPORT PAYMENTS: TOTAL FIXED COSTS (A-H): 2.

3.

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. 5. Entertainment: Vacations: Gifts: Religious Contributions: Dues and Subscriptions: Club Memberships & Dues: TOTAL DISCRETIONARY EXPENSES: ADDITIONAL EXPENSES: 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 1, line 9.C. 5. 4.

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 6 - FORM 8.010.5 ­ Uniform Support Affidavit of Petitioner G Respondent G Co-petitioner G ­ 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 27