Fill and Sign the Fillable Online Law Umich Patron Application to Check Form

FL-155 Your name and address or attorney's name and address: TELEPHONE NO.: ATTORNEY FOR (Name): FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: FINANCIAL STATEMENT (SIMPLIFIED) CASE NUMBER: NOTICE: Read page 2 to find out if you qualify to use this form and how to use it.1.a. My only source of income is TANF, SSI, or GA/GR. (If you check this box, skip to item 8. ) b. I have applied for TANF, SSI, or GA/GR. 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) : 4. My tax filing status is: single married filing jointly head of household married filing separately. 5.My current gross income (before taxes) per month (specify amount): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ This income comes from the following: Salary (wages): Amount before taxes per month (specify amount): . . . . . . . . . . . . . . . . . . . . . $ Retirement: Amount before taxes per month (specify amount): . . . . . . . . . . . . . . . . . . . . . . . . $ Unemployment compensation: Amount per month (specify amount): . . . . . . . . . . . . . . . . . . . $ Worker's compensation: Amount per month (specify amount): . . . . . . . . . . . . . . . . . . . . . . . $ Social Security SSI Other Amount per month (specify amount):. . . . . . . . . . . . . . $ Disability: Amount per month (specify amount):. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Interest income f(rom bank accounts and other) Amount per month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ I have no income other than as stated in this paragraph.6. I pay the following monthly expenses for the children in this case:a. Day care or preschool to allow me to work or go to school (specify amount): . . . . . . . . . . . . . . . . . . . . . . $ b. Health care not paid for by insurance (specify amount) :. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ c. School, education, tuition, or other special needs of the child (specify amount): . . . . . . . . . . . . . . . . . . . . $ d. Travel expenses for visitation (specify amount): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 7. There are (specify number) other minor children of mine living with me. Their monthly expenseswhich I pay are): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 8. I spend the following average monthly amounts (please attach proof):a. Jo b-re la te d e xp ense s t h at a re n ot p aid b y m y e m plo ye r ( s p ecif y r e aso ns f o r e xp ense on o n s e para te s h eet . . . . . . . $ b. Required union dues (specify amount):. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ c. Required retirement payments (not social Security or FICA) (specify amount): . . . . . . . . . . . . . . . . . . . . . $ d. Health insurance costs (specify amount): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ e. Child support I am paying for other minor children of mine who are not living with me (specify amount): . $ f. Spousal support I am paying because of a court order for another relationship (specify amount):. . . . . . . $ g. Monthly housing costs: rent or mortgage (specify amount): . . . . . . . . . . . . . . . . . . . . . . . . .$ if mortgage: interest payments $ real property taxes $ 9. Information concerning my current employment my most recent employment: Employer: Address: Telephone number: Occupation: Date work started: (Continued on reverse) Form Adopted by for Optional UseJudicial Council of California FL-155 [Rev. January 1, 2004] FINANCIAL STATEMENT (SIMPLIFIED) (Family Law) electronic form 2004 WWW.LawCA.com Law PublishersAttach 1 copy of pay stubs for last 2 months here (cross out social security numbers) MARRIAGE OF (last name, first name of parties): CASE NUMBER: 10. My estimate of the other party's gross monthly income (before taxes) is (specify amount): . . . . . . . . . . . . . . . .$ 11. Other information I want the court to know concerning child support in my case (attach extra sheet with the information).I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.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 andany 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 change in spousal support? Are you asking the other party to pay your attorney fees? Is the other party asking you to pay that party's attorney fees? Do you receive money (income) from any source other than the following? Welfare (such as AFDC, GR, or GA) Salary or Wages Disability Unemployment Worker's Compensation Social Security Retirement Are you self-employed?If y o u a re e lig ib le to u se th is fo rm a nd c h oose to d o s o , y o u d o n ot n eed to c o m ple te th e In co m e a nd E xp ense De cla ra tio n (F orm F L-1 50). E ve n if y o u a re e lig ib le to u se th is fo rm , y o u m ay c h oose in ste ad to u se th e In co m e a nd Exp ense D ecla ra tio n ( F orm F L-1 50).S te p 2 : M ake 2 c o pie s o f e ac h o f y o ur 3 m ost r e cen t p ay s tu bs. If y o u re ce iv e d m oney fr o m o th er th an w ages o f sa la ry , in clu de c o pie s o f t h e p aym ent n otic e r e ce iv e d w it h t h at m oney.P riv a cy n otic e : If y o u w is h , y o u m ay c ro ss o ut y o ur S ocia l S ecu rit y N um ber if it a ppears o n th e w age s tu b o r o th er pa ym en t n otic e .S te p 3 : M ake 2 c o pie s o f y o ur m ost r e cen t f e d era l i n co m e t a x f o rm .Ste p 4 : C om ple te t h is f o rm w it h t h e r e q uir e d in fo rm atio n . T yp e th e fo rm if p ossib le o r c o m ple te it n eatly a nd c le arly in b la ck in k. If y o u n eed a ddit io nal r o om , p le ase u se p la in o r lin ed p aper, 8 ½ " x 1 1", a nd s ta ple t o t h is f o rm .Ste p 5 : M ake 2 c o pie s o f e ach s id e o f t h is c o m ple te d f o rm a n d a n y a tta ch ed p ag es.S te p 6 : S erv e a c o py o n th e o th er p arty . H ave s o m eone o th er th an y o urs e lf m ail to th e a tto rn ey fo r th e o th er p arty , th e o th e r p arty , o r th e D is tr ic t A tto rn ey o ne c o py o f th is fo rm , o ne c o py o f e ach o f y o ur th re e m ost r e ce nt p ay s tu bs, a n d one c o p y o f y o ur m ost r e ce nt f e dera l in co m e t a x r e tu rn .S te p 7 : F ile th e o rig in al w it h th e c o urt. S ta ple th is fo rm w it h o ne c o py o f e ach o f y o ur th re e m ost re ce nt p ay s tu b s. Ta ke t h is d ocu m ent a nd g iv e it t o t h e c le rk o f t h e c o urt.S te p 8 : K eep t h e r e m ain in g c o pie s o f t h e d ocu m en ts f o r y o ur f ile . S te p 9 : B rin g t h e c o py o f y o ur l a te st f e d era l i n co m e t a x r e tu rn t o t h e c o urt h earin g.It is v ery im porta n t th at y o u a tte n d th e h earin gs s ch ed ule d fo r th is c ase. If y o u d o n ot a tte n d a h earin g, th e co u rt m ay m ake a n o rd er w it h out c o nsid erin g t h e i n fo rm atio n y o u w an t t h e c o urt t o c o nsid er.Rev January 1, 2004 FINANCIAL STATEMENT (SIMPLIFIED) (Family Law) electronic form 2004 WWW.LawCA.com Law Publishers