Uniform Support Declaration – Fill Out and Use This PDF

) 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

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)

B.Other Sources of Your Monthly Income: (Attach verification of your gross monthly income as listed below):

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

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?

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

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):

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

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.

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)

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:

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:

A.

B.

C.

D.

E.

F.

TOTAL PAYMENTS ON CONSUMER OBLIGATIONS (A-F):

3.SUMMARY OF EXPENSES:

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)