Oregon Uniform Support Declaration

UNIFORM SUPPORT DECLARATION

IN THE CIRCUIT COURT OF THE STATE OF OREGON

FOR COUNTY

In the Matter of:

SUMMARY INFORMATION – COMPLETE THIS PAGE LAST

After completing Sections 1 through 5, on Pages 2 through 5 below, insert the information and/or total MONTHLY amounts in this Summary Information section. Date of Completion

1. Number of Joint Children From This Relationship:

2. Number of Joint Children Over 18 But Under 21 Attending School:

3. Number of Nonjoint Additional Children:

4. Gross Monthly Income From All Sources: $

5. Receiving Temporary Assistance for Needy Families? Yes No

6. Child(ren) on Oregon Health Plan/Healthy Kids or Other Public Health Plan? Yes No

7. Social Security or Veteran’s Benefits Received for Child(ren): $

Person with Disability is: Child Me Other Parent

8. Spousal Support RECEIVED by You: $

9. Spousal Support PAID by You: $

10. Mandatory Union Dues Paid: $

11. Health Care Premiums for Yourself: $

12. Health Care Premiums Paid for Joint Child(ren): $

13. Out-of-Pocket Medical Expenses Paid for Joint Child(ren): $

14. Number of ANNUAL Overnights Child(ren) Spends With You:

15. Childcare Expenses Paid for Joint Child(ren): $

16. City Where Childcare is Provided:

1. CHILDREN

A. *List all JOINT CHILDREN (children under the age of 21 born or adopted during this relationship):

B. *List all NONJOINT ADDITIONAL CHILDREN (children under the age of 21 born to or adopted by you but not of this relationship).

2. YOUR GROSS INCOME

A. From Your Employment:

Subtotal of Monthly Income From Employment (5) + (6) SUBTOTAL: 2.A.

B. Other Sources of Your Monthly Income:

*Total of 2A + 2B Enter here and on Page 1, #4 TOTAL:

C. *Do you receive Temporary Assistance for Needy Families? Yes, $ monthly No

D. *Do you receive Social Security or Veteran’s benefits for any joint child(ren) due to parent’s disability? Yes, $ monthly No

Name of Beneficiary Child(ren) Name of Disabled Parent Source

E. *Do you receive Social Security or Veteran’s benefits for any joint child(ren) due to child’s disability? Yes, $ monthly No

Name of Child(ren) Source

F. *Is there an order for you to RECEIVE spousal support from your spouse involved in this proceeding? Yes, $ monthly No

G. *Is there an order for you to RECEIVE spousal support from a former/subsequent spouse? Yes, $ monthly No

H. *Are you ordered to PAY spousal support? Yes, $ monthly No

If Yes, to whom?

I. *Do you pay mandatory union dues? Yes, $ monthly No

3. HEALTH CARE COVERAGE AND MEDICAL EXPENSES

A. *Is there a cost to insure just yourself? Yes No

B. Do you provide health care coverage for your joint child(ren)? Yes No

C. Does someone else provide health care coverage for your joint child(ren)? Yes No

Name of person, or entity, providing, if other than you:

D. Are you or any member of your household:

i. Enrolled in the Oregon Health Plan, Healthy Kids, or any other public health care coverage? Yes No

ii. Receiving a state subsidy for public or private health care coverage? Yes No

E. Are any of the joint children enrolled in public health care coverage (Healthy Kids/Oregon Health Plan)?

Name of child(ren) enrolled? Yes No

If you answered “YES” to A, B, C, D, or E above:

i. Name all persons covered:

Relationship to you:

ii. What is the source of the insurance? (such as through your employer, spouse, other):

iii. Insurance Co.: Phone Number:

iv. Monthly amount of any state subsidy received by your household for public or private health-care coverage $

v. Policy Number: Group Number:

vi. Address for submission of claims:

vii. Your total monthly premium cost: (A)$; Cost to cover only you: (B)*$; Total number of people enrolled (not counting yourself): (C); Number of joint children enrolled: (D)

*The cost for the joint child(ren) only is (A – B) ÷ C = $ x D = *$

viii. ATTACH PROOF OF INSURANCE PREMIUMS.

F. *Do you pay any out-of-pocket medical expenses (not covered by insurance) for any joint child(ren) on a monthly basis? Yes No

G. Does anyone pay a share of the monthly out-of-pocket medical costs for the child(ren)? Yes No

If yes, who? ; amount they pay? $

4. YOUR CHILDCARE EXPENSES

A. *Do you pay for childcare for the joint child(ren) so you can work, train, or look for work? Yes No

B. *Does anyone else share the cost of childcare for the joint child(ren)? Yes No

If yes, name: Average Monthly Amount $

C. *City where childcare is provided:

5. *YOUR PARENTING TIME

PROPOSED OCCURRING EXISTING PLAN OR WRITTEN AGREEMENT

6. YOUR REBUTTAL FACTORS

A. The amount of child support to be paid may be rebutted under OAR 137-050-0760.

i. Are you seeking a rebuttal (an adjustment to the support amount)? Yes No

ii. Explain briefly:

ATTACHMENT CHECKLIST

Check the box and include the appropriate attachment(s).

Four most recent pay stubs or benefit statements

Most recent state and federal tax returns (including all applicable schedules)

Proof of insurance premiums

Proof of medical costs

Most recent parenting plan or written agreement

Proof of childcare costs

Copies of Spousal and Child Support Orders

Additional Page: Number items to correspond, include your name and case number

Other:

CERTIFICATE OF MAILING

I hereby certify that I served a true and complete copy of this Uniform Support Declaration and all attachments by mailing it first class mail, with postage prepaid, on to the following people:

1.

Address:

2.

Address:

SCHEDULE 1 - Spousal/Registered Domestic Partner Support Factors

You must complete this schedule and prepare and submit the attachments requested in this schedule if either party seeks spousal support or deviation from the uniform child support guidelines.

1. FIXED COSTS:

2. CONSUMER OBLIGATIONS:

3. SUMMARY OF EXPENSES:

4. OTHER FACTORS: