Free FL-155 FINANCIAL STATEMENT (SIMPLIFIED) - California

COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. TELEPHONE NO.: Your name and address or attorney's name and address: : Index No. :
ATTORNEY FOR (Name):

FL-155
FOR COURT USE ONLY

Calendar No.

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

Plaintiff(s)

: : : :

JUDICIAL SUBPOENA

-against-

PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT:

Defendant(s) : ......................................................
FINANCIAL STATEMENT (SIMPLIFIED)

CASE NUMBER:

My only source of income is TANF, SSI, or GA/GR. 1. a. I have applied for TANF, SSI, or GA/GR. b. TO 2. I am the parent of the following number of natural or adopted children from this relationship . . . . . . . . . . . . . . . . . . 3. a. The children from this relationship are with me this amount of time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. The children from this relationship are with the other parent this amount of time . . . . . . . . . . . . . . . . . . . . . . . . . . c. Our arrangement for custody and visitation is (specify, using extra sheet if necessary):

THE PEOPLE OF THE STATE OF NEW YORK

NOTICE: Read page 2 to find out if you qualify to use this form and how to use it.

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GREETINGS:

married filing jointly head of household married filing separately. single 4. My tax filing status is: 5. My current gross income (before taxes) per month is . . . . .and excuses .being laid. aside, .you .and .each. of .you attend before .......... ........ ..... ... ... ... .. ...$ WE COMMAND YOU, that all business This the Honorable income comes from the following: at the Court Attach 1 Salary/wages: Amount before taxes per month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ copy of pay located at County of Retirement: Amount before taxes per month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ stubs for in room , on the day of , 20 , at o'clock in the noon, and at any recessed Unemployment compensation: Amount per month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ last 2 or adjourned date, to testify and give evidence as amonth . . in .this .action. on. the . . . . . . .the. . . . . . . . . . . $ witness . . . . . . . . . . . . . part of . . months here Workers' compensation: Amount per (cross out Social security: SSI Other Amount per month . . . . . . . . . . . . . . . . . . . . . . . . . . $ social Disability: Amount per month . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ security Interest income ( from bank accounts or other): Amount per month . . . . . . . . . . . . . . . . . . . . . $ numbers) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to I have no income other than as stated in this paragraph. the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a 6. I pay the following monthly expenses for the children in this case: result of your failure to comply. me to work or go to school . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Day care or preschool to allow a. Health care not paid for by insurance . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ b. c. School, education, tuition, or other special needs of the child . . . . . . . . . . . . . ., .. . . . of . . . .Justices. of .the Witness, Honorable one . . the . . . . . . . . . $ Travel expenses for visitation . . .day of . . . . . . . . . . . ., .20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ d. Court in ..... .. County, There are (specify number) other minor children of mine living with me. Their monthly expenses that I pay are . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 8. I spend the following average monthly amounts (please attach proof): a. Job-related expenses that are not paid by my employer (specify (Attorneyfor expenses onand type name below) reasons must sign above separate sheet) $ Required union dues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ b. Required retirement payments (not social security, FICA, 401k or IRA) . . . . . . . . . . . . . . .. . . . . . . . . . . . . $ c. .......... Health insurance costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Attorney(s) . . . . . . . . . . . . . . . . . . . . . . . $ d. for Child support I am paying for other minor children of mine who are not living with me . .. . . . . . . . . . . . . . . . $ e. f. Spousal support I am paying because of a court order for another relationship . . . . . . . . . . . . . . . . . . . . . . . $ rent or Monthly housing costs: mortgage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ g. If mortgage: interest payments $____________ real property taxes $____________ Office and P.O. Address my current employment 9. Information concerning my most recent employment: Employer: Address: Telephone number: My occupation: Telephone No.: Date work started: Facsimile No.: Date work stopped (if applicable): What was your gross income (before taxes) before work stopped?:
Form Approved for Optional Use Judicial Council of California FL-155 [Rev. January 1, 2004]

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7.

E-Mail Address: Mobile Tel. FINANCIAL STATEMENT (SIMPLIFIED) No.:

Page 1 of 2 Family Code, § 4068(b) www.courtinfo.ca.gov

American LegalNet, Inc. www.USCourtForms.com

PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT:

CASE NUMBER:

10. My estimate of the other party's gross monthly income (before taxes) is . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . $ 11. My current spouse's monthly income (before taxes) is . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . $ 12. Other information I want the court to know concerning child support in my case (attach extra sheet with the information). 13. I am attaching a copy of page 3 of form FL-150, Income and Expense Declaration showing my expenses. 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) (SIGNATURE OF DECLARANT) PETITIONER/PLAINTIFF RESPONDENT/DEFENDANT

INSTRUCTIONS
Step 1: Are you eligible to use this form? If your answer is YES to any of the following questions, you may NOT use this form: · Are you asking for spousal support (alimony) or a change in spousal support? · Is your spouse or former spouse asking for spousal support (alimony) or a change in spousal support? · Are you asking the other party to pay your attorney fees? · Is the other party asking you to pay his or her attorney fees? · Do you receive money (income) from any source other than the following? · Welfare (such as TANF, GR, or GA) · Salary or wages · Disability · Unemployment · Are you self-employed? If you are eligible to use this form and choose to do so, you do not need to complete the Income and Expense Declaration (form FL-150). Even if you are eligible to use this form, you may choose instead to use the Income and Expense Declaration (form FL-150). Step 2: Make 2 copies of each of your pay stubs for the last two months. If you received money from other than wages or salary, include copies of the pay stub received with that money. Privacy notice: If you wish, you may cross out your social security number if it appears on the pay stub, other payment notice or your tax return Step 3: Make 2 copies of your most recent federal income tax form. Step 4: Complete this form with the required information. Type the form if possible or complete it neatly and clearly in black ink. If you need additional room, please use plain or lined paper, 8½-by-11", and staple to this form. Step 5: Make 2 copies of each side of this completed form and any attached pages. Step 6: Serve a copy on the other party. Have someone other than yourself mail to the attorney for the other party, the other party, and the local child support agency, if they are handling the case, 1 copy of this form, 1 copy of each of your stubs for the last two months, and 1 copy of your most recent federal income tax return. Step 7: File the original with the court. Staple this form with 1 copy of each of your pay stubs for the last two months. Take this document and give it to the clerk of the court. Check with your local court about how to submit your return. Step 8: Keep the remaining copies of the documents for your file. Step 9: Take the copy of your latest federal income tax return to the court hearing. It is very important that you attend the hearings scheduled for this case. If you do not attend a hearing, the court may make an order without considering the information you want the court to consider. · Interest · Workers' compensation · Social security · Retirement

FL-155 [Rev. January 1, 2004]

FINANCIAL STATEMENT (SIMPLIFIED)

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