Free FL-150.v5.092806..ofm - California


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FL-150
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY

TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME:

PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT/CLAIMANT:
CASE NUMBER:

INCOME AND EXPENSE DECLARATION

1. Employment (Give information on your current job or, if you're unemployed, your most recent job.) a. Employer: Attach copies b. Employer's address: of your pay c. Employer's phone number: stubs for last d. Occupation: two months (black out e. Date job started: social f. If unemployed, date job ended: security hours per week. g. I work about numbers). gross (before taxes) per month per week h. I get paid $

per hour.

(If you have more than one job, attach an 8-by-11-inch sheet of paper and list the same information as above for your other jobs. Write "Question 1--Other Jobs" at the top.) 2. Age and education a. My age is (specify): b. I have completed high school or the equivalent: Yes c. Number of years of college completed (specify): d. Number of years of graduate school completed (specify): professional/occupational license(s) (specify): e. I have: vocational training (specify): 3. Tax information a. I last filed taxes for tax year (specify year): single head of household married, filing separately b. My tax filing status is married, filing jointly with (specify name): c. I file state tax returns in California other (specify state): d. I claim the following number of exemptions (including myself) on my taxes (specify): 4. Other party's income. I estimate the gross monthly income (before taxes) of the other party in this case at (specify): $ This estimate is based on (explain): (If you need more space to answer any questions on this form, attach an 8-by-11-inch sheet of paper and write the question number before your answer.) Number of pages attached: I declare under penalty of perjury under the laws of the State of California that the information contained on all pages of this form and any attachments is true and correct. Date:
(TYPE OR PRINT NAME) Form Adopted for Mandatory Use Judicial Council of California FL-150 [Rev. January 1, 2007] (SIGNATURE OF DECLARANT)

If no, highest grade completed (specify): No Degree(s) obtained (specify): Degree(s) obtained (specify):

INCOME AND EXPENSE DECLARATION

Page 1 of 4 Family Code, 20302032, 21002113, 3552, 36203634, 40504076, 43004339 www.courtinfo.ca.gov American LegalNet, Inc. www.FormsWorkflow.com

FL-150
PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT/CLAIMANT:
CASE NUMBER:

Attach copies of your pay stubs for the last two months and proof of any other income. Take a copy of your latest federal tax return to the court hearing. (Black out your social security number on the pay stub and tax return.) 5. Income (For average monthly, add up all the income you received in each category in the last 12 months and divide the total by 12.) a. Salary or wages (gross, before taxes). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ b. Overtime (gross, before taxes) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ c. Commissions or bonuses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ d. Public assistance (for example: TANF, SSI, GA/GR) e. Spousal support from this marriage currently receiving . . . . . . . . . . . . . . . . . $ from a different marriage . . . . . . . . . . . . . . . . . . $ Average Last month monthly

f. Partner support from this domestic partnership from a different domestic partnership $ g. Pension/retirement fund payments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ h. Social security retirement (not SSI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ i. j. Disability: Social security (not SSI) State disability (SDI) Private insurance . $ Unemployment compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

k. Workers' compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ l. Other (military BAQ, royalty payments, etc.) (specify): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 6. Investment income (Attach a schedule showing gross receipts less cash expenses for each piece of property.) a. Dividends/interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ b. Rental property income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ c. Trust income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ d. Other (specify): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Income from self-employment, after business expenses for all businesses. . . . . . . . . . . . . . . . . . . . . $ I am the owner/sole proprietor business partner other (specify): Number of years in this business (specify): Name of business (specify): Type of business (specify): Attach a profit and loss statement for the last two years or a Schedule C from your last federal tax return. Black out your social security number. If you have more than one business, provide the information above for each of your businesses. 8. Additional income. I received one-time money (lottery winnings, inheritance, etc.) in the last 12 months (specify source and amount): Change in income. My financial situation has changed significantly over the last 12 months because (specify):

7.

9.

10. Deductions Last month a. Required union dues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ b. Required retirement payments (not social security, FICA, 401(k), or IRA). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ c. Medical, hospital, dental, and other health insurance premiums (total monthly amount). . . . . . . . . . . . . . . . . . . . . . . . $ d. Child support that I pay for children from other relationships. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ e. Spousal support that I pay by court order from a different marriage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ f. Partner support that I pay by court order from a different domestic partnership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ g. Necessary job-related expenses not reimbursed by my employer (attach explanation labeled "Question 10g") . . . . . $ 11. Assets a. Cash and checking accounts, savings, credit union, money market, and other deposit accounts . . . . . . . . . . . . . . . . $ b. Stocks, bonds, and other assets I could easily sell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ c. All other property,
FL-150 [Rev. January 1, 2007]

Total

real

and

personal

(estimate fair market value minus the debts you owe) . . . .

$
Page 2 of 4

INCOME AND EXPENSE DECLARATION

FL-150
PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT/CLAIMANT:
CASE NUMBER:

12. The following people live with me: Name a. b. c. d. e. 13. Average monthly expenses a. Home: (1) Rent or If mortgage: (a) average principal: $ (b) average interest: $ (2) Real property taxes . . . . . . . . . . . . . . $ (3) Homeowner's or renter's insurance (if not included above) . . . . . . . . . . . . $ (4) Maintenance and repair . . . . . . . . . . . $ b. Health-care costs not paid by insurance. . . $ c. Child care . . . . . . . .. . . . . . . . . . . . . . . . . . $ d. Groceries and household supplies. . . . . . . $ e. Eating out. . . . . . . . . . . . . . . . . . . . . . . . . . $ f. Utilities (gas, electric, water, trash) . . . . . . $ s. q. r. Estimated expenses h. mortgage. . . $ i. j. k. l. Actual expenses Age That person's gross How the person is related to me? (ex: son) monthly income Pays some of the household expenses? Yes Yes Yes Yes Yes Proposed needs No No No No No

Laundry and cleaning . . . . . . . . . . . . . . . . . $ Clothes . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Education . . . . . . . . . . . . . . . . . . . . . . . . . . $ Entertainment, gifts, and vacation. . . . . . . . $ Auto expenses and transportation (insurance, gas, repairs, bus, etc.) . . . . . . . $

m. Insurance (life, accident, etc.; do not include auto, home, or health insurance). . . $ n. o. p. Savings and investments. . . . . . . . . . . . . . . $ Charitable contributions. . . . . . . . . . . . . . . . $ Monthly payments listed in item 14 (itemize below in 14 and insert total here). . $ Other (specify): . . . . . . . . . . . . . . . . . . . . . . $ TOTAL EXPENSES (aq) (do not add in the amounts in a(1)(a) and (b)) Amount of expenses paid by others

$ $

g. Telephone, cell phone, and e-mail . . . . . . . $ 14. Installment payments and debts not listed above Paid to For

Amount $ $ $ $ $ $

Balance $ $ $ $ $ $

Date of last payment

15. Attorney fees (This is required if either party is requesting attorney fees.): a. b. c. d. To date, I have paid my attorney this amount for fees and costs (specify): $ The source of this money was (specify): I still owe the following fees and costs to my attorney (specify total owed): $ My attorney's hourly rate is (specify): $

I confirm this fee arrangement. Date:
(TYPE OR PRINT NAME OF ATTORNEY) FL-150 [Rev. January 1, 2007] (SIGNATURE OF ATTORNEY)

INCOME AND EXPENSE DECLARATION

Page 3 of 4

FL-150
PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT/CLAIMANT:
CASE NUMBER:

CHILD SUPPORT INFORMATION (NOTE: Fill out this page only if your case involves child support.) 16. Number of children a. I have (specify number): children under the age of 18 with the other parent in this case. b. The children spend percent of their time with me and percent of their time with the other parent. (If you're not sure about percentage or it has not been agreed on, please describe your parenting schedule here.)

17. Children's health-care expenses I do not have health insurance available to me for the children through my job. I do a. b. Name of insurance company: c. Address of insurance company:

d. The monthly cost for the children's health insurance is or would be (specify): $ (Do not include the amount your employer pays.) 18. Additional expenses for the children in this case a. Child care so I can work or get job training. . . . . . . . . . . . . . . . . . . . . . . . . b. Children's health care not covered by insurance . . . . . . . . . . . . . . . . . . . . c. Travel expenses for visitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d. Children's educational or other special needs (specify below): . . . . . . . . Amount per month $ $ $ $

19. Special hardships. I ask the court to consider the following special financial circumstances (attach documentation of any item listed here, including court orders): Amount per month a. Extraordinary health expenses not included in 18b. . . . . . . . . . . . . . . . . . $ b. Major losses not covered by insurance (examples: fire, theft, other insured loss) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c. (1) Expenses for my minor children who are from other relationships and are living with me . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (2) Names and ages of those children (specify): $ $

For how many months?

(3) Child support I receive for those children. . . . . . . . . . . . . . . . . . . . . . .

$

The expenses listed in a, b, and c create an extreme financial hardship because (explain):

20. Other information I want the court to know concerning support in my case (specify):

FL-150 [Rev. January 1, 2007]

INCOME AND EXPENSE DECLARATION

Page 4 of 4