Medi Cal Redetermination Form – Fill Out and Use

FL-150

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):		FOR COURT USE ONLY
	TELEPHONE NO.:
E-MAIL ADDRESS (Optional):
	ATTORNEY FOR (Name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
	STREET ADDRESS:
	MAILING ADDRESS:
	CITY AND ZIP CODE:
	BRANCH NAME:
	PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT/CLAIMANT:
	INCOME AND EXPENSE DECLARATION	CASE NUMBER:

(If you have more than one job, attach an 8½-by-11-inch sheet of paper and list the same information as above for your other jobs. Write "Question 1—Other Jobs" at the top.)

2.Age and education

a.My age is (specify):

b. I have completed high school or the equivalent: Yes c. Number of years of college completed (specify):

d. Number of years of graduate school completed (specify):

e.I have: professional/occupational license(s) (specify):

vocational training (specify):

3.Tax information

a. I last filed taxes for tax year (specify year):

b.

My tax filing status is

single

head of household

married, filing separately

c.

married, filing jointly with (specify name):

I file state tax returns in

California

other (specify state):

d.I claim the following number of exemptions (including myself) on my taxes (specify):

4.Other party's income. I estimate the gross monthly income (before taxes) of the other party in this case at (specify): $ This estimate is based on (explain):

(If you need more space to answer any questions on this form, attach an 8½-by-11-inch sheet of paper and write the question number before your answer.) Number of pages attached:

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)

Page 1 of 4

FL-150

Attach copies of your pay stubs for the last two months and proof of any other income. Take a copy of your latest federal tax return to the court hearing. (Black out your social security number on the pay stub and tax return.)

6.Investment income (Attach a schedule showing gross receipts less cash expenses for each piece of property.)

a. Dividends/interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ b. Rental property income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ c. Trust income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ d. Other (specify): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

7. Income from self-employment, after business expenses for all businesses. . . . . . . . . . . . . . . . . . . . . $

I am the owner/sole proprietor business partner other (specify):

Number of years in this business (specify):

8.

9. Change in income. My financial situation has changed significantly over the last 12 months because (specify):

10. Deductions		Last month
a. Required union dues		$
b.	Required retirement payments (not social security, FICA, 401(k), or IRA)
		$
c.
	Medical, hospital, dental, and other health insurance premiums (total monthly amount)	$
d.	Child support that I pay for children from other relationships	$
e.	Spousal support that I pay by court order from a different marriage	$
f.	Partner support that I pay by court order from a different domestic partnership	$
g.	Necessary job-related expenses not reimbursed by my employer (attach explanation labeled "Question 10g")	$

11. Assets					Total
a. Cash and checking accounts, savings, credit union, money market, and other deposit accounts					$
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .b. Stocks, bonds, and other assets I could easily sell					$
c. All other property,		real and		personal (estimate fair market value minus the debts you owe)	$

FL-150

12.The following people live with me:

		How the person is	That person's gross	Pays some of the
Name	Age	related to me? (ex: son)	monthly income	household expenses?
a.						Yes					No
b.						Yes					No
c.						Yes					No
d.						Yes					No
e.						Yes					No

13. Average monthly expenses												Estimated expenses							Actual expenses		Proposed needs
a.	Home:															h.		Laundry and cleaning				$
	(1)				Rent or			mortgage				. $				i.		Clothes				$
																j.		Education				$
		If mortgage:
		(a)		average principal: $												k.		Entertainment, gifts, and vacation				$
		(b)		average interest:				$								l.		Auto expenses and transportation
	(2)		Real property taxes						. . .	. . .	. .	$.						(insurance, gas, repairs, bus, etc.)				$
	(3) Homeowner's or renter's insurance															m.		Insurance (life, accident, etc.; do not
																		include auto, home, or health insurance)				$
			(if not included above)									$
	(4)							. .	. . .	. . .	. . .					n.		Savings and investments				$
			Maintenance and repair									$
																o.		Charitable contributions				$
b.	Health-care costs not paid by insurance											$
																p.		Monthly payments listed in item 14
c.	Child care										.	$
								. . .	. . . .	.							(itemize below in 14 and insert total here). .				$
d.	. . . . . .Groceries and household supplies											. $				q.		. . . . . . . . . . . . . . . . . . . . . .Other (specify):				$
e.	Eating out										.	$
								. . .	. . . .	.					r.		TOTAL EXPENSES (a–q) (do not add in
f.	Utilities (gas, electric, water, trash)
												$.						the amounts in a(1)(a) and (b))				$
g.	Telephone, cell phone, and e-mail											$
																s.		Amount of expenses paid by others				$

14.Installment payments and debts not listed above

Paid to	For	Amount	Balance	Date of last payment
		$	$
		$	$
		$	$
		$	$
		$	$
		$	$

15.Attorney fees (This is required if either party is requesting attorney fees.):

a.To date, I have paid my attorney this amount for fees and costs (specify): $

b.The source of this money was (specify):

c.I still owe the following fees and costs to my attorney (specify total owed): $

d.My attorney's hourly rate is (specify): $

I confirm this fee arrangement.

Date:

(TYPE OR PRINT NAME OF ATTORNEY)

(SIGNATURE OF ATTORNEY)

FL-150

CHILD SUPPORT INFORMATION

(NOTE: Fill out this page only if your case involves child support.)

16.Number of children

a. I have (specify number): children under the age of 18 with the other parent in this case.

b. The children spend percent of their time with me and percent of their time with the other parent.

(If you're not sure about percentage or it has not been agreed on, please describe your parenting schedule here.)

17.Children's health-care expenses

a.

I do

I do not

have health insurance available to me for the children through my job.

b.Name of insurance company:

c.Address of insurance company:

d.The monthly cost for the children's health insurance is or would be (specify): $ (Do not include the amount your employer pays.)

18. Additional expenses for the children in this case	Amount per month
a. Child care so I can work or get job training	$
b. Children's health care not covered by insurance	$
c. Travel expenses for visitation	$
d. Children's educational or other special needs (specify below):	$
19. Special hardships. I ask the court to consider the following special financial circumstances
(attach documentation of any item listed here, including court orders):	Amount per month				For how many months?
a. Extraordinary health expenses not included in 18b	$
b. Major losses not covered by insurance (examples: fire, theft, other
insured loss)	$
c. (1) Expenses for my minor children who are from other relationships and
are living with me	$

(2) Names and ages of those children (specify):

(3) Child support I receive for those children

$

The expenses listed in a, b, and c create an extreme financial hardship because (explain):

20.Other information I want the court to know concerning support in my case (specify):