The Medi Cal Redetermination Form is a crucial form that is used to determine eligibility for the Medi-Cal program. This form must be completed by all applicants and renewal applicants, and any changes in income or household composition must be reported as soon. The information on this form will help determine whether an individual or family is eligible for Medi-Cal, and how much assistance they will receive. Make sure to complete this form accurately and thoroughly to ensure the best possible outcome for you or your family.
This figure features information about medi cal redetermination form. It might be beneficial to know its size, the actual time needed to complete the form, the fields you'll have to fill in, etc.
Question | Answer |
---|---|
Form Name | Medi Cal Redetermination Form |
Form Length | 4 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min |
Other names | medi cal redetermination, annual redetermination recertification, dpss lacounty gov annual redetermination en español, medi cal forms online |
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): |
FOR COURT USE ONLY |
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TELEPHONE NO.: |
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ATTORNEY FOR (Name): |
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SUPERIOR COURT OF CALIFORNIA, COUNTY OF |
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STREET ADDRESS: |
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MAILING ADDRESS: |
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CITY AND ZIP CODE: |
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BRANCH NAME: |
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PETITIONER/PLAINTIFF: |
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RESPONDENT/DEFENDANT: |
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OTHER PARENT/CLAIMANT: |
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INCOME AND EXPENSE DECLARATION |
CASE NUMBER: |
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1.Employment (Give information on your current job or, if you're unemployed, your most recent job.)
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Employer: |
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Attach copies |
b. |
Employer's address: |
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of your pay |
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c. |
Employer's phone number: |
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stubs for last |
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d. |
Occupation: |
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two months |
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(black out |
e. |
Date job started: |
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social |
f. |
If unemployed, date job ended: |
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security |
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g. |
I work about |
hours per week. |
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numbers). |
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h. |
I get paid $ |
gross (before taxes) |
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per month |
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per week |
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per hour.
(If you have more than one job, attach an
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):
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My tax filing status is |
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single |
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head of household |
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married, filing separately |
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c. |
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married, filing jointly with (specify name): |
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I file state tax returns in |
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California |
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other (specify state): |
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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
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
Form Adopted for Mandatory Use
Judicial Council of California
INCOME AND EXPENSE DECLARATION
Family Code, §§
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT/CLAIMANT:
CASE NUMBER:
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.)
5.Income (For average monthly, add up all the income you received in each category in the last 12 months and divide the total by 12.)
a. |
Salary or wages (gross, before taxes) |
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b. |
Overtime (gross, before taxes) |
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c. |
Commissions or bonuses |
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d. |
Public assistance (for example: TANF, SSI, GA/GR) |
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currently receiving |
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e. |
Spousal support |
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from this marriage |
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from a different marriage . |
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f. |
Partner support |
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from this domestic partnership |
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from a different domestic partnership $ |
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g. |
Pension/retirement fund payments |
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h. |
Social security retirement (not SSI) |
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i. |
Disability: |
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Social security (not SSI) |
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State disability (SDI) |
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Private insurance . $ |
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j. |
Unemployment compensation |
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k. |
Workers' compensation |
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l. |
Other (military BAQ, royalty payments, etc.) (specify): |
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Average Last month monthly
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
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 |
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a. Required union dues |
$ |
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b. |
Required retirement payments (not social security, FICA, 401(k), or IRA) |
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$ |
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c. |
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Medical, hospital, dental, and other health insurance premiums (total monthly amount) |
$ |
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d. |
Child support that I pay for children from other relationships |
$ |
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e. |
Spousal support that I pay by court order from a different marriage |
$ |
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f. |
Partner support that I pay by court order from a different domestic partnership |
$ |
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g. |
Necessary |
$ |
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11. Assets |
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Total |
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a. Cash and checking accounts, savings, credit union, money market, and other deposit accounts |
$ |
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .b. Stocks, bonds, and other assets I could easily sell |
$ |
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c. All other property, |
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real and |
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personal (estimate fair market value minus the debts you owe) |
$ |
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INCOME AND EXPENSE DECLARATION
Page 2 of 4
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT/CLAIMANT:
CASE NUMBER:
12.The following people live with me:
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How the person is |
That person's gross |
Pays some of the |
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Name |
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related to me? (ex: son) |
monthly income |
household expenses? |
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a. |
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Yes |
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No |
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b. |
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Yes |
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No |
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c. |
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Yes |
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No |
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d. |
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Yes |
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No |
e. |
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Yes |
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No |
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13. Average monthly expenses |
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Estimated expenses |
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Actual expenses |
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Proposed needs |
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a. |
Home: |
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h. |
Laundry and cleaning |
$ |
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(1) |
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Rent or |
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mortgage |
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i. |
Clothes |
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j. |
Education |
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If mortgage: |
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(a) |
average principal: $ |
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k. |
Entertainment, gifts, and vacation |
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(b) |
average interest: |
$ |
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l. |
Auto expenses and transportation |
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(2) |
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Real property taxes |
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$. |
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(insurance, gas, repairs, bus, etc.) |
$ |
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(3) Homeowner's or renter's insurance |
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m. |
Insurance (life, accident, etc.; do not |
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include auto, home, or health insurance) |
$ |
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(if not included above) |
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$ |
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(4) |
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n. |
Savings and investments |
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$ |
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Maintenance and repair |
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o. |
Charitable contributions |
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b. |
$ |
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p. |
Monthly payments listed in item 14 |
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c. |
Child care |
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$ |
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. . . |
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(itemize below in 14 and insert total here). . |
$ |
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d. |
. . . . . .Groceries and household supplies |
. $ |
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q. |
. . . . . . . . . . . . . . . . . . . . . .Other (specify): |
$ |
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e. |
Eating out |
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$ |
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. . . |
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r. |
TOTAL EXPENSES |
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f. |
Utilities (gas, electric, water, trash) |
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$. |
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the amounts in a(1)(a) and (b)) |
$ |
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g. |
Telephone, cell phone, and |
$ |
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s. |
Amount of expenses paid by others |
$ |
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14.Installment payments and debts not listed above
Paid to |
For |
Amount |
Balance |
Date of last payment |
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$ |
$ |
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$ |
$ |
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$ |
$ |
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$ |
$ |
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$ |
$ |
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$ |
$ |
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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) |
INCOME AND EXPENSE DECLARATION
Page 3 of 4
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT/CLAIMANT:
CASE NUMBER:
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
a. |
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I do |
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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 |
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a. Child care so I can work or get job training |
$ |
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b. Children's health care not covered by insurance |
$ |
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c. Travel expenses for visitation |
$ |
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d. Children's educational or other special needs (specify below): |
$ |
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19. Special hardships. I ask the court to consider the following special financial circumstances |
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(attach documentation of any item listed here, including court orders): |
Amount per month |
For how many months? |
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a. Extraordinary health expenses not included in 18b |
$ |
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b. Major losses not covered by insurance (examples: fire, theft, other |
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insured loss) |
$ |
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c. (1) Expenses for my minor children who are from other relationships and |
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are living with me |
$ |
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(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):
INCOME AND EXPENSE DECLARATION
Page 4 of 4