FL-155 Form – Fill Out and Use This PDF

Enter your name and address or attorney's name and address, the Telephone No., the Attorney for (Name), the Superior Court of California, County of, its Street Address, Mailing Address, City and Zip Code and Branch Name. Enter the Petitioner/Plaintiff, Respondent/Defendant, Other Parent and Case Number. (For Court Use Only)

Check the box for My only source of income is TANF, SSI, or GA/GR. or the box for I have applied for TANF, SSI, or GA/GR.

Enter the number of natural or adopted children from this relationship that you are the parent of, the amount of time (%) the children from this relationship are with you and the amount of time (%) they are with the other parent. Specify your arrangement for custody and visitation, using extra sheet if necessary.

Mark your tax filing status: head of household, married filing separately, married filing jointly or single. Enter your current gross income (before taxes) per month.

Attach 1 copy of pay stubs for last 2 months here (cross out social security numbers). Enter the Amount before taxes per month for Salary/wages and Retirement, and the Amount per month for Unemployment compensation, Workers' compensation, Social security (SSI, Other or Disability) and Interest income (from bank accounts or other). The form states: I have no income other than as stated in this paragraph.

Under I pay the following monthly expenses for the children in this case, enter Day care or preschool to allow me to work or go to school, Health care not paid for by insurance, School, education, tuition, or other special needs of the child and Travel expenses for visitation.

Specify the number of other minor children of yours living with you, and enter the average monthly amounts you spend on them (please attach proof).

Enter the monthly Job-related expenses that are not paid by my employer (specify reasons for expenses on separate sheet), Required union dues, Required retirement payments (not social security, FICA, 401k or IRA), Health insurance costs. Enter the monthly Spousal support I am paying because of a court order for another relationship, Child support I am paying for other minor children of mine who are not living with me and Monthly housing costs: rent or mortgage. If mortgage, enter the interest payments and the real property taxes.

Under Information concerning my current employment or my most recent employment, enter the Employer, Address, Telephone number, My occupation and Date work started. Enter the Date work stopped (if applicable) and the gross income (before taxes) before work stopped.

Enter My estimate of the other party's gross monthly income (before taxes) and My current spouse's monthly income (before taxes).

Check the box if you are attaching a copy of page 3 of form FL-150, Income and Expense Declaration showing your expenses.

Attach an extra sheet with the other information you want the court to know concerning child support in your case.

You 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. Enter the Date, the SIGNATURE OF DECLARANT and the TYPE OR PRINT NAME, and mark PETITIONER/PLAINTIFF or RESPONDENT/DEFENDANT.

If your answer is YES to any of the following questions, you may NOT use this form: Is your spouse or former spouse asking for spousal support (alimony) or a change in spousal support? Are you asking for spousal support (alimony) or a change in spousal support? Are you asking the other party to pay your attorney fees? Is the other party asking you to pay his or her attorney fees? Do you receive money (income) from any source other than the following: Welfare (such as TANF, GR, or GA), Salary or wages, Disability, Unemployment, Interest, Workers' 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).

FL-155 is the FINANCIAL STATEMENT (SIMPLIFIED), a Form Approved for Optional Use of the Judicial Council of California. The NOTICE: Read page 2 to find out if you qualify to use this form and how to use it.

Staple this form with 1 copy of each of your pay stubs for the last two months. Take this document and give it to the clerk of the court. Check with your local court about how to submit your return.