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.

QuestionAnswer
Form NameUniform Support Declaration
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namesoregon uniform support declaration form, oregon declaration, uniform support declaration oregon, oregon declarations form

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IN THE CIRCUIT COURT OF THE STATE OF OREGON

 

FOR ____________________ COUNTY

In the Matter of:

)

Case No.

 

)

 

 

,

)

Judge Assigned:

 

 

)

 

 

 

Petitioner Co-Petitioner,

)

Check one box:

 

 

)

PETITIONER’S RESPONDENT’S

and

)

CO-PETITIONER’S CO-RESPONDENTS or

)OTHER:

,)

)UNIFORM SUPPORT DECLARATION

Respondent Co-Respondent. )

)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 - FORM 8.010.5 UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G CO-PETITIONER G CO-RESPONDENT G OTHER G UTCR 8.010(4), 8.010(7), 8.040(3), 8.040(4), 8.050(1), 8.050(3)

(Revised 8-1-12)

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

Age

2.YOUR GROSS INCOME A. From Your Employment:

 

 

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 - FORM 8.010.5 UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G CO-PETITIONER G CO-RESPONDENT G OTHER G UTCR 8.010(4), 8.010(7), 8.040(3), 8.040(4), 8.050(1), 8.050(3)

(Revised 8-1-12)

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 - FORM 8.010.5 UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G CO-PETITIONER G CO-RESPONDENT G OTHER G UTCR 8.010(4), 8.010(7), 8.040(3), 8.040(4), 8.050(1), 8.050(3)

(Revised 8-1-12)

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 - FORM 8.010.5 UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G CO-PETITIONER G CO-RESPONDENT G OTHER G UTCR 8.010(4), 8.010(7), 8.040(3), 8.040(4), 8.050(1), 8.050(3)

(Revised 8-1-12)

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://www.dcs.state.or.us/oregon_admin_rules/default.htm

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.

DATED this

 

day of

 

, 20 .

 

 

 

 

 

 

 

My (printed) Name Is

I am:

PETITIONER RESPONDENT CO-PETITIONER

OTHER:

SIGNATURE

Page 5 - FORM 8.010.5 UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G CO-PETITIONER G CO-RESPONDENT G OTHER G UTCR 8.010(4), 8.010(7), 8.040(3), 8.040(4), 8.050(1), 8.050(3)

(Revised 8-1-12)

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:

 

 

 

 

 

 

SIGNATURE

Page 6 - FORM 8.010.5 UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G CO-PETITIONER G CO-RESPONDENT G OTHER G UTCR 8.010(4), 8.010(7), 8.040(3), 8.040(4), 8.050(1), 8.050(3)

(Revised 8-1-12)

SCHEDULE 1

Spousal/Registered Domestic Partner Support Factors

You must complete this schedule and prepare and submit the attachments requested in this schedule if either party seeks spousal support. 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 - FORM 8.010.5 UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G CO-PETITIONER G CO-RESPONDENT G OTHER G UTCR 8.010(4), 8.010(7), 8.040(3), 8.040(4), 8.050(1), 8.050(3)

(Revised 8-1-12)

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 - FORM 8.010.5 UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G CO-PETITIONER G CO-RESPONDENT G OTHER G UTCR 8.010(4), 8.010(7), 8.040(3), 8.040(4), 8.050(1), 8.050(3)

(Revised 8-1-12)

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