Form Csf 01 0100 PDF Details

Doctors and nurses are some of the most highly educated professionals in the world. With so much on their plate, it's important that they have the right tools to do their job effectively. One such tool is the Csf 01 0100 form. This form allows doctors and nurses to document and track a patient's progress while they're in the hospital. It's an important part of ensuring that patients receive quality care. In this blog post, we'll discuss what the Csf 01 0100 form is, what it's used for, and why it's important. We'll also take a look at some common mistakes that doctors and nurses make when using this form. By understanding how to use this form correctly, you can ensure that your patients receive the best possible care.

QuestionAnswer
Form NameForm Csf 01 0100
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namescsf010100 uniform income and expense statement oregon

Form Preview Example

STATE OF OREGON, Child Support Program (CSP), by the Administrator (ORS 25.010)

County:

Court #:

CSP #:

[

] Other Jurisdiction:

 

Case #:

Children:

 

 

Obligor:

 

 

Obligee:

 

 

[

] Other parties:

 

 

U n if or m I n com e & Ex p e n se St a t e m e n t

Contact information:

 

 

 

 

 

 

Cell #:

 

 

 

Text? Yes No

 

Message #:

 

Home #:

 

 

Email:

 

 

 

 

 

 

 

 

Date

Signature

 

Printed Name

 

 

 

 

 

 

Address

 

City

State

 

Zip

The address you list above will be your “contact address.” We will use it to send documents to you. It will also appear in legal papers given to the other parent and in court records. If you do not want your residence or mailing address to be given to the other party or appear in court records, you must give us a different address in your state for the CSP to use as your “contact address.” If the address you give now is different than one you gave us before, we will use the new one from now on.

List all ‘Joint Children’ in this Order (children under the age of 21, born to or adopted by the parties)

Name of Child

Date

 

Children Living With:

Child 18-20 in

If Child 18, in

 

of

 

 

 

 

School

High School

 

Birth

 

 

 

 

 

 

 

 

 

 

 

Other

 

Yes

No

Yes

No

 

 

Me

Parent

Other (Name)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List your additional joint children on a separate sheet of paper.

Do you already have a support order for these children? Yes No If yes, explain and attach the

most recent copy of your orders, if available:

Do you have a parenting time order or written parenting time agreement for these children?

Yes No If yes, attach a copy of the order or agreement.

Page 1 of 4 - UNIFORM INCOME & EXPENSE STATEMENT

CSF 01 0100 (Rev. 04/18/14) CSCM Initials CSP#:

Do you support other children in your home or have a support order for children not in your home?

Yes No If yes, list them below.

Child’s First Name

Date of

Relationship

If there is an order for you to

Birth

(daughter,

pay support, provide state,

 

son, etc.)

county & court number.

 

 

 

Child 18 in

High School

in Your Home

Yes No

List biological and adopted children or stepchildren you are ordered to support. List other children you support on a separate piece of paper.

Do you pay or receive spousal support? Yes No

Amount paid: $

 

 

to whom

 

Amount received: $

 

 

 

from whom

 

Are you employed? Yes

No

Name, address, & phone number of employer:

How many hours per week do you work?

 

 

Do you consistently receive wages for overtime

hours? Yes No

 

 

 

 

 

What is your monthly income before deductions? $

 

. Attach a copy of your most recent

pay stub.

 

 

 

 

 

Do you pay mandatory union dues? Yes No

If yes, how much per month? $

 

 

Do you receive expense reimbursements or allowances for a car, cell phone, housing, subsidies, or any other expenses which reduce your living expenses? Yes No If yes, how much per month? $ Attach proof you receive expense reimbursements or allowances.

Are you unemployed? Yes No

Are you receiving workers' compensation or unemployment benefits? Yes No

If yes, list the source and the amount of the monthly or weekly benefit:

Source:

 

Amount: $

Monthly Weekly

 

 

 

 

 

What type of work have you done in the last five years?

Why did your last job end?

Are you self-employed? Yes No

Name, address, & phone number of your business:

Attach a copy of your most recent tax return (personal and business, including all schedules) or profit & loss statement.

Page 2 of 4 - UNIFORM INCOME & EXPENSE STATEMENT

CSF 01 0100 (Rev. 04/18/14) CSCM Initials CSP#:

Do you have other income? Yes No Income includes but is not limited to, commissions, advances, bonuses, dividends, severance pay, pensions, interest, Social Security benefits, disability insurance benefits, prizes, lottery, alimony, Supplemental Security income, and distributions from a trust.

Income does not include child support, food stamp benefits, Social Security resulting from a child’s disability, adoption assistance, guardianship assistance, and foster care subsidies.

Source:

 

 

Amount: $

 

Source:

 

 

Amount: $

 

Do you have child care costs for the ‘Joint’ children?

Yes No

Are the children 12 years old or under? Yes No

Are the children disabled? Yes No

If you answered yes to either question, list the name(s) of the children, date(s) of birth and amount(s) you pay for their care and attach proof of child care costs: (Only include the costs you pay out of pocket.)

Amount: $

Amount: $

Amount: $

Amount: $

Are you paying for your own health care coverage? Yes No If yes, what is your monthly cost?

$. Attach proof of coverage showing your monthly cost.

Is health care coverage available for your children? Yes No If yes, who insures the children?

Source of insurance: employer other group

spouse domestic partner other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance Co.:

 

 

 

 

 

 

Phone #:

 

Address

 

 

 

 

 

 

 

 

 

 

Policy #:

 

Group #:

 

 

Effective date of the policy:

 

Monthly cost per child $

 

 

Name(s) of children currently covered by insurance:

 

Do you pay ongoing medical expenses for the children? Yes No

If yes, list the name(s) of children, the reason for the expense, and the monthly cost: Amount: $

Amount: $

Attach proof of insurance and ongoing medical expenses for the children.

Do any of your children receive Social Security or Veteran’s benefits due to a parent=s disability or retirement? Yes No

What type of benefit do they receive?

Survivors and Dependents Educational Assistance

Social Security benefits

Apportioned Veteran’s benefits due to the disability or retirement of a parent What is the total monthly benefit amount the children receive? $

If your child is in state care, do you have regular visits? Yes No

If so, how far do you travel?

How often do you visit?

Does the Department of Human Services pay any of these expenses? Yes No

Page 3 of 4 - UNIFORM INCOME & EXPENSE STATEMENT

CSF 01 0100 (Rev. 04/18/14) CSCM Initials CSP#:

Do you have court ordered counseling or classes that you must attend?

Yes

No

If yes, what are your expenses associated with these classes? $

 

 

 

Do you have a medical condition that prevents you from working? Yes No

 

Attach proof of disability (SSA award letter, doctor’s diagnosis of disability).

 

Do you have court or attorney fees associated with the children in care?

Yes

No

If yes, list the fees:

 

 

 

Do you have to pay probation fees? Yes No If yes, how much? $

Are there any additional expenses or needs you want us to consider when calculating your child support?

Amount of the expense: $

 

How does it affect your ability to pay support?

Are there any other special circumstances that you want us to consider?

Is there any information you can provide about the other parent?

If you need more room to answer any of these questions, attach a separate piece of paper.

Are you represented by an attorney for child support matters?

Yes

No

If yes, please provide the attorney name and contact information below.

 

 

 

 

Attorney Name

Phone #

 

Fax #

 

 

 

 

Address

 

City/State

Zip

The Child Support Program can provide you with information from forms and other notices in your own language free of charge. This also includes Braille, large print, and the use of interpreters. To find out more, contact your child support office.

The Child Support Program (CSP) provides services for the State of Oregon. We cannot represent you or give you legal advice. You may contact your own lawyer at any time. Low cost legal services may be available. For information, you may visit the CSP website at oregonchildsupport.gov.

Division of Child Support

`

` ` `

Telephone: ` FAX: `

TTY: (800) 735-2900

Page 4 of 4 - UNIFORM INCOME & EXPENSE STATEMENT

CSF 01 0100 (Rev. 04/18/14) CSCM Initials CSP#:

How to Edit Form Csf 01 0100 Online for Free

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Step 2: The editor enables you to work with PDF files in many different ways. Enhance it with customized text, correct existing content, and place in a signature - all manageable in no time!

This form requires some specific details; in order to guarantee consistency, make sure you take heed of the subsequent guidelines:

1. You have to fill out the Form Csf 01 0100 accurately, so be careful while working with the areas containing all of these blank fields:

Writing segment 1 in Form Csf 01 0100

2. Soon after completing the last step, head on to the subsequent stage and complete all required details in all these blanks - List your additional joint, Do you already have a support, and Do you have a parenting time order.

Stage no. 2 of filling out Form Csf 01 0100

3. The next part will be straightforward - fill out all of the fields in Do you support other children in, Childs First Name, Date of, Relationship, Birth, daughter son etc, If there is an order for you to, county court number, and Child in High School in Your Home to conclude this part.

Part # 3 of filling out Form Csf 01 0100

It is possible to make a mistake while filling out your Relationship, for that reason ensure that you take a second look before you submit it.

4. This next section requires some additional information. Ensure you complete all the necessary fields - List biological and adopted, Amount paid, Amount received, to whom, from whom, Are you employed Yes No, Name address phone number of, How many hours per week do you, Do you consistently receive wages, What is your monthly income before, Attach a copy of your most recent, Do you receive expense, Are you unemployed Yes No, Are you receiving workers, and If yes list the source and the - to proceed further in your process!

Form Csf 01 0100 completion process shown (step 4)

5. Because you come close to the completion of the document, you will find several more requirements that need to be met. Mainly, What type of work have you done in, Why did your last job end, Are you selfemployed Yes No, Name address phone number of your, Attach a copy of your most recent, and Page of UNIFORM INCOME EXPENSE must be filled in.

Step number 5 of filling in Form Csf 01 0100

Step 3: After taking one more look at your fields, press "Done" and you're done and dusted! Sign up with FormsPal now and immediately use Form Csf 01 0100, prepared for download. Every modification made is conveniently preserved , so that you can modify the pdf at a later point when required. FormsPal is dedicated to the personal privacy of all our users; we ensure that all personal data used in our editor is confidential.

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