Uniform Support Declaration PDF Details

A Uniform Support Declaration, or USS, is a legal document used in custody cases to help parents agree on support payments for their children. The USS sets forth the specific terms of child support payments, including how much and how often the payments will be made. A USS can be helpful in ensuring that both parents are on the same page when it comes to supporting their children financially. If you are considering creating a USS with your ex-spouse, consult with an experienced family law attorney first. They can help you draft a document that meets both of your needs and complies with state law.

This information will aid you to comprehend better the details of the uniform support declaration before you start filling it out.

Question	Answer
Form Name	Uniform Support Declaration
Form Length	9 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 15 sec
Other names	uniform support declaration fillable, declaration oregon, oregon union support declatation form, oregon drought declaration

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UNIFORM SUPPORT DECLARATION

The Uniform Support Declaration must be completed when the payment of child or spousal support is or could be an issue in the case.

The USD provides basic information about expenses and ability to pay.

CAUTION:

Please read the instructions for and use UTCR 2.130 forms to separate social security numbers, dates of birth and other private information from public records.

It is your responsibility to black out (redact) any confidential information on the attachments or copies. Examples of confidential information that should be redacted are social security numbers, dates of birth, checking account information, etc.

Do not bring the originals of your attachments, such as paystubs and tax returns, and expect the court to make photocopies to attach to your Uniform Support Declaration. You are responsible for making copies and ensuring they are on 8½” x 11” paper.

IN THE CIRCUIT COURT OF THE STATE OF OREGON

FOR WASHINGTON COUNTY

In the Matter of:		Case No.
		Judge Assigned:
 Petitioner	 Co-Petitioner	Check one box:
		 PETITIONER  RESPONDENT
and		 CO-PETITIONER
		 OTHER:
		UNIFORM SUPPORT DECLARATION
		UNIFORM SUPPORT DECLARATION
 Respondent	 Co-Petitioner
		OR CSP Case No.

SUMMARY INFORMATION—COMPLETE THIS PAGE LAST

After completing Sections 1 through 5, on Pages 2 through 5 below, insert the information and/or total MONTHLY amounts in this Summary Information section.

		Date of Completion	_______________
			mm/dd/year
1.	Number of Joint Children From This Relationship:		_______________
2.	Number of Joint Children Over 18 But Under 21 Attending School:		_______________
3.	Number of Nonjoint Additional Children:		_______________
4.	Gross Monthly Income From All Sources:		$_______________
5.	Receiving Temporary Assistance for Needy Families?		 Yes	 No
6.	Child(ren) on Oregon Health Plan/Healthy Kids or Other Public Health Plan?		 Yes	 No
7.	Social Security or Veteran’s Benefits Received for Child(ren):		$_______________
	Person with Disability is:  Child  Me	 Other Parent
8.	Spousal Support RECEIVED by You:		$_______________
9.	Spousal Support PAID by You:		$_______________
10.	Mandatory Union Dues Paid:		$_______________
11.	Health Care Premiums for Yourself Only if You Provide Insurance for Child(ren): $_______________
12.	Health Care Premiums Paid for Joint Child(ren):		$_______________
13.	Out-of-Pocket Medical Expenses Paid for Joint Child(ren):		$_______________
14.	Number of ANNUAL Overnights Child(ren) Spends With You:		_______________
15.	Childcare Expenses Paid for Joint Child(ren):		$_______________
16.	City Where Childcare is Provided:	____________________________________________

Page 1—UNIFORM SUPPORT DECLARATION (December 2019)

This form is a DECLARATION under penalty of perjury required for support determinations. It must be completed in its entirety, signed, filed with the court or appropriate administrative agency, and served upon the other party (or their attorney).

INSTRUCTIONS: Answer all questions. Items marked with an * should be transferred to Page 1. If you are seeking spousal support, you need to complete Schedule 1. Attach additional page if needed.

IMPORTANT: This information will be disclosed to the other party and may be subject to public access. Protections are available using the court’s “Confidential Information Form” process.

1.CHILDREN

A. *List all JOINT CHILDREN (children under the age of 21 born or adopted during this relationship):

		Children Living With:			Over 18 & Under		21
					Attending School
Name of Child	Age	Me	Other Parent	Other	Yes	No

B.*List all NONJOINT ADDITIONAL CHILDREN (children under the age of 21 born to or adopted by you but not of this relationship).

Name

2.YOUR GROSS INCOME

A. From Your Employment:

Age

	Description			Monthly Amount
1	Gross hourly wage.
2	Average number of hours worked per pay period.	x
3	Convert to annual. If paid monthly, enter “12”. If paid twice	x
	monthly, enter “24”. Every two weeks, enter “26”. Every
	week, enter “52”.
4	Convert to monthly.	÷	12
5	Gross monthly income: 1. x 2. x 3. ÷ 4.
6	Gross monthly tips/commissions/bonuses (identify):
Subtotal of Monthly Income From Employment (5) + (6)		SUBTOTAL: 2.A.

Page 2—UNIFORM SUPPORT DECLARATION

B.Other Sources of Your Monthly Income:

(Attach verification of your gross monthly income as listed below):

Description		Monthly Amount
Self-Employment
Dividends
Interest Income
Trust Income
Annuity Income
Social Security Income
Workers’ Compensation Benefits per week multiplied by 52; divided by 12
Unemployment Benefits per week multiplied by 52; divided by 12
Disability Income
Expense Reimbursements and/or Per Diem Allowance not listed in item A. above
Other (specify source/type)
Other (specify source/type):
SUBTOTAL: 2.B.
*Total of 2A + 2B Enter here and on Page 1, #4	TOTAL:
C. *Do you receive Temporary Assistance for Needy Families?	 Yes, $________ monthly  No

D.*Do you receive Social Security or Veteran’s benefits for any joint child(ren) due to parent’s disability?

Name of Beneficiary Child(ren) _______________________ Yes, $________ monthly  No

Name of Disabled Parent ____________________________ Source

E.*Do you receive Social Security or Veteran’s benefits for any joint child(ren) due to child’s disability?

 Yes, $________ monthly  No

Name of Child(ren) _________________________________ Source

F. *Is there an order for you to RECEIVE spousal support from your spouse involved in this proceeding?

 Yes, $________ monthly  No

G. *Is there an order for you to RECEIVE spousal support from a former/subsequent spouse?

	 Yes, $________ monthly	 No
H. *Are you ordered to PAY spousal support?	 Yes, $________ monthly	 No
If Yes, to whom? __________________________________
I. *Do you pay mandatory union dues?	 Yes, $________ monthly	 No

J.ATTACH A COPY OF YOUR FOUR MOST RECENT PAY STUB(S), BENEFIT STATEMENTS, AND COPIES OF YOUR MOST RECENTLY FILED STATE AND FEDERAL TAX RETURNS.

ATTACH COPIES OF SPOUSAL SUPPORT ORDERS AND ANY CHILD SUPPORT ORDERS FOR NONJOINT ADDITIONAL CHILD(REN) NOT LIVING WITH YOU.

Page 3—UNIFORM SUPPORT DECLARATION

3.HEALTH CARE COVERAGE AND MEDICAL EXPENSES

A.	*Is there a cost to insure just yourself if you provide insurance for the child(ren)?	 Yes	 No
B.	Do you provide health care coverage for your joint child(ren)?	 Yes	 No
C. Does someone else provide health care coverage for your joint child(ren)?		 Yes	 No
	Name of person, or entity, providing, if other than you:

D.Are you or any member of your household:

i. Enrolled in the Oregon Health Plan, Healthy Kids, or any other public health care coverage?

	 Yes	 No
ii. Receiving a state subsidy for public or private health care coverage?	 Yes	 No

E. Are any of the joint children enrolled in public health care coverage (Healthy Kids/Oregon Health Plan)? Name of child(ren) enrolled? _________________________________________  Yes  No

If you answered “YES” to A, B, C, D, or E above:

i.Name all persons covered: Relationship to you:

ii.What is the source of the insurance? (such as through your employer, spouse, other):

iii. Insurance Co.:

Phone Number:

iv.Monthly amount of any state subsidy received by your household for public or private health-care coverage $____________.

v. Policy Number:

Group Number:

vi.Address for submission of claims:

vii.Your total monthly premium cost: (A)$____________; Cost to cover only you: (B)*$____________;

Total number of people enrolled (not counting yourself): (C)____________; Number of joint

children enrolled: (D)______

*The cost for the joint child(ren) only is (A – B) ÷ C = $____________ x D = *$____________

viii.ATTACH PROOF OF INSURANCE PREMIUMS.

F. *Do you pay any out-of-pocket medical expenses (not covered by insurance) for any joint child(ren) on

a monthly basis?		 Yes  No
If yes, list the name of the child, the reason for the cost(s), and the amount per month:
i.	; $

ii.	; $

iii.	; $

iv.	; $

G.Does anyone pay a share of the monthly out-of-pocket medical costs for the child(ren)?

Yes  No

If yes, who?		; amount they pay? $

H.ATTACH PROOF OF MONTHLY MEDICAL EXPENSES.

Page 4—UNIFORM SUPPORT DECLARATION

4.YOUR CHILDCARE EXPENSES

A. *Do you pay for childcare for the joint child(ren) so you can work, train, or look for work?  Yes  No

If yes,:

Paid to:	Name of Child	Age	Average Monthly Payment

B. *Does anyone else share the cost of childcare for the joint child(ren)?		 Yes  No
If yes, name:	Average Monthly Amount $

C.*City where childcare is provided:

D.ATTACH COPIES OF PROOF OF CHILDCARE EXPENSES.

5.*YOUR PARENTING TIME

 PROPOSED

 OCCURRING

 EXISTING PLAN OR WRITTEN AGREEMENT

A.How many ANNUAL overnights does each joint child spend with YOU?

i.Name of Child: ___________________________________ # of overnights: _______________

ii.Name of Child: ___________________________________ # of overnights: _______________

iii.Name of Child: ___________________________________ # of overnights: _______________

iv.Name of Child: ___________________________________ # of overnights: _______________

B.ATTACH COPY OF MOST RECENT PARENTING PLAN OR WRITTEN AGREEMENT.

6.YOUR REBUTTAL FACTORS

A.The amount of child support to be paid may be rebutted under OAR 137-050-0760. http://oregonchildsupport.gov/laws/rules/docs/050_0760.pdf

i.	Are you seeking a rebuttal (an adjustment to the support amount)?		 Yes  No
ii.	Explain briefly:

B. ATTACH SUPPORTING EVIDENCE/ADDITIONAL INFORMATION.

I HEREBY DECLARE THAT THE ABOVE STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND THAT I UNDERSTAND THEY ARE MADE FOR USE AS EVIDENCE IN COURT AND ARE SUBJECT TO PENALTY FOR PERJURY.

Signature

Printed Name

Date

I am:  PETITIONER  RESPONDENT  CO-PETITIONER  OTHER:

Page 5—UNIFORM SUPPORT DECLARATION

ATTACHMENT CHECKLIST: Check the box and include the appropriate attachment(s).

Four most recent pay stubs or benefit statements

Most recent state and federal tax returns (including all applicable schedules)

Proof of insurance premiums

Proof of medical costs

Most recent parenting plan or written agreement

Proof of childcare costs

Copies of Spousal and Child Support Orders

Additional Page: Number items to correspond, include your name and case number

Other: _________________________________

CERTIFICATE OF MAILING

I hereby certify that I served a true and complete copy of this Uniform Support Declaration and all attachments

by mailing it first class mail, with postage prepaid, on(date) to the following people:

1.		(Other Party/Attorney name)
	Address:

2.			(name)
	Address:

Date

Signature

Page 6—UNIFORM SUPPORT DECLARATION

SCHEDULE 1

Spousal/Partner and Child Support Factors

You must complete this schedule and prepare and submit the attachments requested in this schedule if either party seeks spousal support or deviation from the uniform child support guidelines. These are the total household expenses you must pay each month for yourself only and not for others in your household. 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 DEDUCTED FROM YOUR WAGES.

1.FIXED COSTS:

	Description	Monthly Amount

A.	RESIDENCE:

	Mortgage or Rent

	Second Mortgage/Home Equity Loan

	Property Taxes (if not included in Mortgage)

	Insurance (if not included in Mortgage)

B.	UTILITIES:

	Electricity

	Gas

	Water

	Garbage

	Telephone

	Cable/Internet

C.	TRANSPORTATION:

	Car Payments

	Fuel

	Maintenance and Repairs

	Other (specify):

D.	INSURANCE:

	Life

	Automobile

	Medical/Dental

	Other (specify):

E. Food and Household Items

F.	Medicine &Pharmaceutical – unreimbursed medical/dental costs

G. Court/DHR-Ordered Support Payments for other than child(ren)/spouse/RDP in
	this case

	TOTAL FIXED COSTS (A-G):

Page 7—UNIFORM SUPPORT DECLARATION

2.	CONSUMER OBLIGATIONS:
			Balance
	Name of Creditor		Due	Monthly Amount

A.

B.

C.

D.

E.

F.

	TOTAL PAYMENTS ON CONSUMER OBLIGATIONS (A-F):

3.	SUMMARY OF EXPENSES:

	Description			Monthly Amount

Fixed Costs (item 1 above)

Consumer Obligations (item 2 above)

		TOTAL EXPENSES:

4.OTHER FACTORS:

Other factors that affect my income and expense or that should be considered (attach supporting documentation whenever possible).

TOTAL:

My (printed) Name is: ____________________________________________

I am:  PETITIONER  RESPONDENT  CO-PETITIONER  OTHER:

Page 8—UNIFORM SUPPORT DECLARATION

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Step 1: To start out, hit the orange button "Get Form Now".

Step 2: At this point, you are on the document editing page. You can add text, edit present information, highlight particular words or phrases, insert crosses or checks, add images, sign the document, erase unneeded fields, etc.

If you want to create the oregon uniform support declaration form PDF, enter the information for each of the segments:

stage 1 to filling in uniform support declaration oregon pdf

Fill in the Number of Nonjoint Additional, Gross Monthly Income From All, Receiving Temporary Assistance, Yes No, Children on Oregon Health, Yes No, Social Security or Veterans, Spousal Support RECEIVED by You, Spousal Support PAID by You, Mandatory Union Dues Paid, Health Care Premiums for Yourself, Health Care Premiums Paid for, OutofPocket Medical Expenses Paid, Number of ANNUAL Overnights, and Childcare Expenses Paid for Joint areas with any content that is demanded by the program.

Completing uniform support declaration oregon pdf part 2

Determine the crucial data in the Name of Child, Age, Other Parent Other, Yes, B List all NONJOINT ADDITIONAL, but not of this relationship, Name, Age, YOUR GROSS INCOME, A From Your Employment, Gross hourly wage, Description, Monthly Amount, Average number of hours worked per, and Convert to annual If paid monthly part.

uniform support declaration oregon pdf Name of Child, Age, Other Parent Other, Yes, B List all NONJOINT ADDITIONAL, but not of this relationship, Name, Age, YOUR GROSS INCOME, A From Your Employment, Gross hourly wage, Description, Monthly Amount, Average number of hours worked per, and Convert to annual If paid monthly fields to fill

The Convert to monthly, Gross monthly income x x, Gross monthly, Subtotal of Monthly Income From, and Page UNIFORM SUPPORT DECLARATION area will be applied to record the rights or responsibilities of both sides.

stage 4 to entering details in uniform support declaration oregon pdf

Fill in the document by taking a look at the next fields: Description, Monthly Amount, SelfEmployment, Dividends, Interest Income, Trust Income, Annuity Income, Social Security Income, Workers Compensation Benefits per, Unemployment Benefits per week, Disability Income, Expense Reimbursements andor Per, Other specify sourcetype, Other specify sourcetype, and Total of A B Enter here and on.

part 5 to completing uniform support declaration oregon pdf

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