Fill and Sign the Oregon Support Child Form

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 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) 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 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) 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 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? Uniform Support Affidavit of Petitioner / Respondent (Child / Spousal Support Case) 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 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) 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 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) 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 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 Uniform Support Affidavit of Petitioner / Respondent (Child / Spousal Support Case) 6 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 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. ________________________ Uniform Support Affidavit of Petitioner / Respondent (Child / Spousal Support Case) 7 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 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: ____________________________ Uniform Support Affidavit of Petitioner / Respondent (Child / Spousal Support Case) 8 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 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. ____________________________ Uniform Support Affidavit of Petitioner / Respondent (Child / Spousal Support Case) 9 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 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. ____________________________ Uniform Support Affidavit of Petitioner / Respondent (Child / Spousal Support Case) 10 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 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): ____________________ ____________________ Uniform Support Affidavit of Petitioner / Respondent (Child / Spousal Support Case) 11 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 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) 12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 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): ___________________________ Uniform Support Affidavit of Petitioner / Respondent (Child / Spousal Support Case) 13 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 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: ___________________ Uniform Support Affidavit of Petitioner / Respondent (Child / Spousal Support Case) 14 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 B. UTILITIES: 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: _____________________ Uniform Support Affidavit of Petitioner / Respondent (Child / Spousal Support Case) 15 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 G. MEDICINE AND PHARMACEUTICAL --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: ____________________ Uniform Support Affidavit of Petitioner / Respondent (Child / Spousal Support Case) 16 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 TOTAL DISCRETIONARY EXPENSES: _____________ 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