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28 IN THE CIRCUIT COURT OF THE STATE OF OREGON
FOR THE COUNTY OF ______________
In the Matter of the Dissolution of Marriage/
Separation of: )
)
)
, ) No._
Petitioner, )
) UNIFORM SUPPORT AFFIDAVIT
OF PETITIONER/ RESPONDENT
) (CHILD/SPOUSAL SUPPORT
CASE)
AND )
)
)
, )
Respondent. )
This form is a SWORN AFFIDAVIT (under oath) required for support determinations. It must
be signed before a notary public, may be made available to the other party, and may be filed in
court. The form consists of this part, on pages 1 through 5, and any attachments requested on
those pages. If either party seeks spousal support or any change from the uniform child support
guidelines, you must also complete the following and the attachments requested therein and
submit all of them with this form:
Schedule 1-Monthly Expenses and Rebutting Factors Required
In addition, certain documentation MUST be attached as indicated on page 2.
Uniform Support Affidavit of Petitioner / Respondent (Child / Spousal Support Case)
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28 STATE OF OREGON )
) ss.
County of __________________ )
I, _______________________, being first duly sworn under oath, depose and say that I
am the _________________ in the above-entitled matter and that the following are true to the
best of my knowledge and belief:
Petitioner/Respondent
I. Your Age: _____ Date of Birth: ______ Social Security Number: _____-______-______
II. Residence Address: _____________________________________________________
III. Name of Employer &Address: ____________________________________________
IV. Occupation: __________________________Title:______________________________
V. Length of Employment: ___________________________________________________
VI. Children born of or adopted during this relationship: _____________________________
Child living with:
Name of Child Age Me Other Parent Other
VII. List all people living in your household (other than children named in item VI above)
Uniform Support Affidavit of Petitioner / Respondent (Child / Spousal Support Case)
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28 Name Age Relationship to You Monthly Income
VIII. List your other dependents or children not listed in items VI or VII above :
Name Age Relationship to You Monthly Income
IX. ENTER THE FOLLOWING INFORMATION FROM SCHEDULES INDICATED:
A. TOTAL GROSS INCOME (From page 4, item 16.D.): ______________________________
B. TOTAL EXPENSES OF CHILDREN (From Schedule 1, item 1.): _____________________
C. TOTAL MONTHLY EXPENSES (From Schedule 1, item 6.): ________________________
______________________________________________________________________________
______________________________________________________________________________
X. (a) Are you or your present spouse entitled to receive court-ordered child support
for any children now living with you?
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28 YES ___ NO ___ If “YES,” complete the following and ATTACH A COPY OF ALL
SUCH CHILD SUPPORT ORDERS.
Name of Child Age Relation to You Support Amount
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(b) Are those support payments being made? YES ____ NO ____
XI. Are you required to pay a court-ordered child support obligation for a child of yours who
is not listed in item 6 above?
YES ____ NO ____ If “YES,” complete the following and ATTACH A COPY OF ALL
CHILD SUPPORT ORDERS .
Name of Child Age Name of Recipient Monthly Support Amount
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Uniform Support Affidavit of Petitioner / Respondent (Child / Spousal Support Case)
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28 12. Are you ordered to pay or entitled to receive court-ordered spousal support? YES ____
NO____ If “YES,” complete the following and ATTACH A COPY OF ALL SUCH SPOUSAL
SUPPORT ORDERS .
Owed To Paid By Monthly Support Amount
Owed Until:_________________________(DateEvent):________________________________
XIII. Are you incurring child care costs on behalf of the children listed in item VI above? YES
____ NO ____ If “YES,” complete the following and attach documentation verifying the
information provided below:
Name of Day-care Provider Monthly (gross amount before application
child and Address cost of any tax credit or subsidy )
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
XIV. Do you receive any subsidy for such care? If so, amount $_________________per
month.
Uniform Support Affidavit of Petitioner / Respondent (Child / Spousal Support Case)
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28 XV. MEDICAL AND DENTAL ELECTIONS--The child support recipient may elect to
require the support payor to name the child(ren) as the beneficiary on a health/dental insurance
plan. If so elected, the child support may be adjusted by an amount equal to all or a portion of the
cost to parent who provides the child’s(ren’s) portion of the health/dental insurance premium.
Please choose:
I wish to require health/dental insurance coverage by the other party and understand that
a portion of the premium may be deducted from support.
I do not wish to require health/dental insurance coverage by the other party.
I provide health/dental insurance through my employer; see page 5, item 18, of this
schedule, for information.
ATTACHMENTS
REQUIRED OPTIONAL
Last four (4) payroll stubs. Child care documentation if you want
this considered
Most recent federal and state income tax return. Medical/dental insurance
documentation
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28 Copies of any and all relevant child/spousal support orders.
(Income, Deductions and Medical/Dental Insurance)
You must complete and submit the following attachments. Copies of recent: (1) federal and state
income tax returns, (2) last four pay stubs, and (3) if self-employed, most recent profits and loss
statement.
XVI. Your Monthly gross Income :
A. From Employment : If paid weekly, multiply weekly income be 4.3 to arrive at a
monthly gross income and insert below. If paid every two weeks, multiple two weeks’
income by 2.15 and insert below:
Description Monthly Amount
Gross Hourly Wage: _______________
Average Number of Hours Worked Per Week: ________________________
Gross Monthly Income: ________________________
Gross Monthly Tips/Commissions/Bonuses (identify): ________________________
SUBTOTAL XVI.A. ________________________
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28 B. From Self-Employment : If you own an interest in partnership or in a closely held
corporation, attach last year’s schedule K-1 and/or corporation federal income tax return:
Description Monthly Amount
Gross Receipts: ___________________________
Expense Reimbursements: ___________________________
Rental Income: ___________________________
Royalty Income: ___________________________
Less Ordinary/Necessary Expenses: (__________________________)
Plus Monthly Portion of Accelerated Component of any Depreciation
Allowance or Investment Tax Credits: ___________________________
SUBTOTAL XVI1.B. ___________________________
C. Other Sources of Income : (Please attach verification of any income available to
you as listed below):
Description Monthly Amount
Dividends: ____________________________
Interest Income: ____________________________
Trust Income: ____________________________
Contract Payments (less underlying debt): ____________________________
Annuity Income: ____________________________
Retirement Benefits-Pension/IRA/Keogh (nonsocial security): ____________________
Social Security Income: ____________________________
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28 Workers’ Compensation Benefits Per Week Multiplied by 4.3 = __________ per month
Unemployment Benefits Per Week Multiplied by 4.3= __________________ per month
Disability Income: ____________________________
Gift or Prizes: ____________________________
Spousal Support: ____________________________
Expense Reimbursements and/or Per Diem Allowance
(not listed in item B. above): ____________________________
ADC Benefits: ____________________________
FCAS (food stamps): ____________________________
Other (specify): ____________________________
____________________________
SUBTOTAL XVII.C. ____________________________
D: Summary of Your Gross Income :
Description Monthly Amount
Income from Employment (item XVI.A. above) ____________________________
Self-Employed Income (item XVIB. above) ____________________________
Other Income (item XVIC. above) ____________________________
_____________________________
YOUR TOTAL MONTHLY GROSS INCOME: ENTER HERE and on this Affidavit Page 2,
line IX.A. XVI.D.
____________________________
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28 XVII. Your Monthly Deductions from Gross Income:
A. Mandatory Deductions:
Number or exemptions claimed by you: ___________________
Description Monthly Amount
State Income Taxes: ____________________________
Federal Income Taxes: ____________________________
Social Security (FICA): ____________________________
Workers’ Compensation Insurance Premium: ____________________________
Wage Withholding, Wage Assignment or Garnishment: _________________________
(Paid to:____________________________________________________)
Medical Insurance for the Parties’ Joint Children if Additional Premium
Total Premium _____________- less cost of coverage for yourself +
other dependents = ____________________________
SUBTOTAL OF MANDATORY: XVII.A. ____________________________
B. Optional Deductions:
Description Monthly Amount
Retirement/Profit Sharing: ____________________________
Savings Plan: ____________________________
Credit Union: ____________________________
Other: ____________________________
SUBTOTAL OF OPTIONAL: XVIIB. ____________________________
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28 C. Summary or Deductions:
Mandatory--from item 17.A. above: ______________________
Optional--from item 17.B. above: ______________________
TOTAL MONTHLY DEDUCTIONS 17.C. ______________________
18. Information for Medical and Dental Insurance Coverage : (For children listed on page 1,
item 6, of this Affidavit which is currently provided or available for the benefit of those
children.):
[ ] I provide this (complete information below) HEALTH INSURANCE
DENTAL INSURANCE
[ ] Other parent provides this (complete if known)
Name of Insurance Company: ____________________ ____________________
Plan or Group Name: ____________________ ____________________
Plan/Group Number: ____________________ ____________________
Individual I.D. Number: ____________________ ____________________
Address for Claims Submission: ____________________ ____________________
Phone Number for Information: ____________________ ____________________
Amount of Annual Deductible: ____________________ ____________________
Gross Monthly Premium Actually Paid by You (exclude amounts paid by your employer):
____________________
____________________
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28 Monthly Premium to Cover Only You: ____________________ ____________________
Dependent’s Portion of Monthly Premium: ____________________ ____________________
Are there dependents other than children on page 1, item 6, of this Affidavit enrolled with plan?
YES ___ NO ___
If Yes, total number or other dependents: ____________________ ____________________
I certify that my answers and this information on this affidavit and the attached schedules
are true to the best of my knowledge and ability. I further certify that the information on the
attached documents is true to the best of my knowledge and ability.
Dated this_____ day of ____________________________, _______.
____________________________________________________
Name
SUBSCRIBED AND SWORN TO BEFORE ME THIS______ DAY
OF__________________________, _______.
____________________________________________________
Notary Public for Oregon
My Commission Expires:________________________________
SCHEDULE 1
(Monthly Expenses and Rebutting Factors)
Uniform Support Affidavit of Petitioner / Respondent (Child / Spousal Support Case)
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28 You must complete this schedule and prepare and submit the attachments requested in this
schedule if either party seeks spousal support or any change from the uniform child support
guidelines. These are the total household expenses you must pay each month. Utility bills should
be averaged over the year. Any other annual, quarterly, or other periodic payments should be
converted to a monthly average. DO NOT LIST ANY EXPENSE IF IT IS DEDUCED FROM
YOU WAGES. ONLY INCLUDE DIRECT EXPENSES FOR JOINT CHILDREN IN
SECTION 1.
I. Direct monthly expenses for children of this relationship which you pay:
AMOUNT
A. School Expenses: __________________________
School Lunches:
__________________________
Books, Tuition: __________________________
Activities: __________________________
Other (Specify): __________________________
B. Food (Other than school lunches): __________________________
C. Day Care: __________________________
D. Clothing: __________________________
E. Medical Insurance--Premium Payments: __________________________
F. Unreimbursed Health Costs: ___________________________
G. Unreimbursed Dental Costs: ___________________________
H. Baby--Sitting (not work-related): ___________________________
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28 I. Lessons: ___________________________
J. Grooming Needs: ___________________________
K. Hobbies, Recreation: ___________________________
L. Entertainment: ___________________________
M. Allowances: ___________________________
N. Transportation: ___________________________
Gasoline, Oil: ___________________________
Insurance for Driving-Age Child: ___________________________
O. Miscellaneous(Specify): ___________________________
___________________________
TOTAL DIRECT EXPENSES OF CHILDREN: ENTER HERE and on Uniform Support
(Add 1.A. thru 1.O.) Affidavit page 2. Line 9.B. 1._______________
Average Monthly Amount of Child’s Income:
Source Amount Name
______________________________________________________________________________
______________________________________________________________________________
II. FIXED COSTS Monthly Amount
A. RESIDENCE:
Mortgage or Rent: ___________________
Property Taxes: ___________________
(If not included in mortgage)
Second Mortgage: ___________________
Other: ___________________
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Electricity: ___________________
Heat (other than electricity): ___________________
Water: ___________________
Garbage: ___________________
Telephone: ___________________
Other: ___________________
C. TRANSPORTATION:
Car Payments: ____________________
Gas &Oil: ____________________
Maintenance & Repairs: ____________________
Other (Specify): ____________________
D. INSURANCE:
Life: ____________________
Automobile: ____________________
Medical/Dental: ____________________
Residence: ____________________
E. FOOD AND HOUSEHOLD ITEMS:____________________
(exclude food expenses for joint children covered in Schedule 1, part 1, above)
F. CLOTHING: _____________________
Grooming/Personal Needs: _____________________
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--Unreimbursed medical/dental costs: _______________
H. OURT/DHR-ORDERED SUPPORT PAYMENTS: __________________
TOTAL FIXED COSTS (A-H): 2. _________
III. CONSUMER OBLIGATIONS:
NAME OF CREDITORS BALANCE DUE MONTHLY PAYMENTS
_______________________ _________________ _____________________
_______________________ _________________ _____________________
_______________________ _________________ _____________________
_______________________ _________________ _____________________
TOTAL MONTHLY PAYMENTS ON CONSUMER OBLIGATIONS: _____________
IV. DISCRETIONARY EXPENSES:
A. Entertainment: ____________________
B. Vacations: ____________________
C. Gifts: ____________________
D. Religious Contributions: ____________________
E. Dues and Subscriptions: ____________________
F. Club Memberships & Dues: ____________________
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V. ADDITIONAL EXPENSES:
_________________________________ ____________________
_________________________________ ____________________
TOTAL ADDITIONAL EXPENSES: ______________________
VI. TOTAL EXPENSES EXCLUDING DIRECT EXPENSES OF CHILD
(Add 2, 3, 4 and 5): ENTER HERE and on Uniform Support Affidavit, page 2, line 9C.
_____________________
VII. Other factors that affect my income and expenses or that should be considered to rebut
the presumptive child support Calculations: (attach supporting documentation whenever
possible).
Uniform Support Affidavit of Petitioner / Respondent (Child / Spousal Support Case)
17
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5.Use the ✔ button, then tap on the Save option to finish editing.
With an easy-to-use interface and total compliance with primary eSignature standards, the airSlate SignNow application is the perfect tool for signing your oregon support child form. It even works offline and updates all form adjustments once your internet connection is restored and the tool is synced. Complete and eSign forms, send them for eSigning, and create multi-usable templates whenever you need and from anyplace with airSlate SignNow.
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