Fill and Sign the Financial Statement Simplified California 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 expenses which 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 reasons for expenseon on separate sheet . . . . . . . $ ––––– 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: ––––– electronic form ã 2004 WWW.LawCA.com Law PublishersAttach 1 copy of pay stubs for last 2 months here (cross out social security numbers) Telephone number: ––––– Occupation: ––––– Date work started: ––––– (Continued on reverse) Form Adopted by for Optional Use Judicial Council of California FL-155 [Rev. January 1, 2004] FINANCIAL STATEMENT (SIMPLIFIED) (Family Law) Form Approved by the Judicial Council of California 1285.52 [New July 1, 1995] FINANCIAL STATEMENT (SIMPLIFIED) (Family Law) Family Code, § 4068(b) www.lawca.com (C) 1997-1998 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 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 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 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 3 most recent pay stubs. If you received money from other than wages of salary, include copies of the payment notice received with that money. Privacy notice: If you wish, you may cross out your Social Security Number if it appears on the wage stub or other payment notice. 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" x 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, or the District Attorney one copy of this form, one copy of each of your three most recent pay stubs, and one copy of your most recent federal income tax return. Step 7: File the original with the court. Staple this form with one copy of each of your three most recent pay stubs. Take this document and give it to the clerk of the court. Step 8: Keep the remaining copies of the documents for your file. Step 9: Bring 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. Rev January 1, 2004 FINANCIAL STATEMENT (SIMPLIFIED) (Family Law) electronic form ã 2004 WWW.LawCA.com Law Publishers