Fill and Sign the Utah Form

- 1 - , Utah Telephone: ( ) - Facsimile: ( ) - ______________________________________________________________________________IN THE JUDICIAL DISTRICT COURT COUNTY, STATE OF UTAH ______________________________________________________________________________ , FINANCIAL VERIFICATION Petitioner, vs. Case No. , Respondent. ______________________________________________________________________________ STATE OF UTAH ) § COUNTY OF ) Pursuant to Section 78-45-7.3, Utah Code Annotated, I, , being first duly sworn and under oath, do hereby submit the financial verification, child support worksheet, and statements required in a default or uncontested proceeding, and do solemnly affirm the following: 1. I am the Petitioner in the above-entitled matter. 2. I have personal knowledge of the facts set forth herein, and if called to testify, I would do so as set forth in this affidavit. - 2 - 3. The child support amount requested is consistent with the guidelines of Section 78-45-7, Utah Code Annotated, as shown by the completed child support worksheet attached hereto as Exhibit A and incorporated herein by this reference. 4. The document(s) attached hereto as Exhibit B and incorporated herein by this reference are true and correct copies of pay stubs, employer statements, tax documents, and/or other documents demonstrating the parties' incomes in this matter. To the extent documents are not available to demonstrate Respondent's income, to the best of my knowledge the income amount specified in the child support worksheet for Respondent accurately reflects Respondent's income. DATED this day of , 20 . _________________________________ Petitioner On this day of , 20 , personally appeared before me , who being first duly sworn, proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to on this instrument, and acknowledged that she voluntarily executed the same. _________________________________ NOTARY PUBLIC Residing At: __________________________ My Commission Expires: ________________ - 3 - MAILING CERTIFICATE I certify I mailed, postage prepaid, by first class mail, a true and correct copy of the foregoing FINANCIAL VERIFICATION to the following, this day of , 20 : , Utah _________________________________ - 4 - EXHIBIT A CHILD SUPPORT WORKSHEET - 5 - EXHIBIT B INCOME VERIFICATION DOCUMENTS