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 |
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Form Name | Uniform Support Declaration |
Form Length | 8 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 2 min |
Other names | oregon 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 |
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FOR ____________________ COUNTY |
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In the Matter of: |
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Case No. |
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Judge Assigned: |
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Petitioner |
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Check one box: |
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PETITIONER’S RESPONDENT’S |
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and |
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) OTHER:
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)UNIFORM SUPPORT DECLARATION
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 |
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mm/dd/year |
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1. |
Number of Joint Children From This Relationship: |
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_______________ |
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2. |
Number of Joint Children Over 18 But Under 21 Attending School: |
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Number of Nonjoint Additional Children: |
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_______________ |
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Gross Monthly Income From All Sources: |
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$_______________ |
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Receiving Temporary Assistance for Needy Families? |
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Yes |
No |
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Child(ren) on Oregon Health Plan/Healthy Kids or Other Public Health Plan? |
Yes |
No |
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Social Security or Veteran’s Benefits Received for Child(ren): |
$_______________ |
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Person with Disability is: Child Me |
Other Parent |
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Spousal Support RECEIVED by You: |
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$_______________ |
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Spousal Support PAID by You: |
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$_______________ |
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Mandatory Union Dues Paid: |
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$_______________ |
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Health Care Premiums for Yourself Only if You Provide Insurance for Child(ren): $_______________ |
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Health Care Premiums Paid for Joint Child(ren): |
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$_______________ |
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$_______________ |
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Number of ANNUAL Overnights Child(ren) Spends With You: |
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Childcare Expenses Paid for Joint Child(ren): |
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$_______________ |
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City Where Childcare is Provided: |
____________________________________________ |
Page 1 - FORM 8.010.5 – UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G
(Revised
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 |
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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:
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Description |
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Monthly Amount |
1 |
Gross hourly wage. |
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2 |
Average number of hours worked per pay period. |
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3 |
Convert to annual. If paid monthly, enter “12”. If paid twice |
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monthly, enter “24”. Every two weeks, enter “26”. Every |
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week, enter “52”. |
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Convert to monthly. |
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12 |
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5 |
Gross monthly income: 1. x 2. x 3. ÷ 4. |
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Gross monthly tips/commissions/bonuses (identify): |
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Subtotal of Monthly Income From Employment (5) + (6) |
SUBTOTAL: 2.A. |
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Page 2 - FORM 8.010.5 – UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G
(Revised
B.Other Sources of Your Monthly Income: (Attach verification of your gross monthly income as listed below):
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Description |
Monthly Amount |
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) |
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Other (specify source/type): |
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SUBTOTAL: 2.B. |
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*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?
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Yes, $________ monthly |
No |
H. *Are you ordered to PAY spousal support? |
Yes, $________ monthly |
No |
If Yes, to whom? __________________________________ |
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I. *Do you pay mandatory union dues? |
Yes, $________ monthly |
No |
J.ATTACH A COPY OF YOUR FOUR MOST RECENT PAY STUB(S), BENEFIT STATEMENTS, AND COPIES OF YOUR MOST RECENTLY FILED STATE AND FEDERAL TAX RETURNS.
ATTACH COPIES OF SPOUSAL SUPPORT ORDERS AND ANY CHILD SUPPORT ORDERS FOR NONJOINT ADDITIONAL CHILD(REN) NOT LIVING WITH YOU.
Page 3 - FORM 8.010.5 – UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G
(Revised
3.HEALTH CARE COVERAGE AND MEDICAL EXPENSES
A. |
*Is there a cost to insure just yourself if you provide insurance for the child(ren)? |
Yes |
No |
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Do you provide health care coverage for your joint child(ren)? |
Yes |
No |
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C. Does someone else provide health care coverage for your joint child(ren)? |
Yes |
No |
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Name of person, or entity, providing, if other than you: |
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D.Are you or any member of your household:
i.Enrolled in the Oregon Health Plan, Healthy Kids, or any other public health care coverage?
Yes No
ii. Receiving a state subsidy for public or private health care coverage? Yes No
E. Are any of the joint children enrolled in public health care coverage (Healthy Kids/Oregon Health Plan)? Name of child(ren) enrolled? _________________________________________ Yes No
If you answered “YES” to A, B, C, D, or E above:
i.Name all persons covered: Relationship to you:
ii.What is the source of the insurance? (such as through your employer, spouse, other):
iii. Insurance Co.: |
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Phone Number: |
iv.Monthly amount of any state subsidy received by your household for public or private
v. Policy Number: |
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Group Number: |
vi.Address for submission of claims:
vii.Your total monthly premium cost: (A)$____________; 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 |
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a monthly basis? |
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Yes |
No |
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If yes, list the name of the child, the reason for the cost(s), and the amount per month: |
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; $ |
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ii. |
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; $ |
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iii. |
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; $ |
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iv. |
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; $ |
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G. Does anyone pay a share of the monthly |
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Yes |
No |
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If yes, who? |
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; amount they pay? $ |
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H.ATTACH PROOF OF MONTHLY MEDICAL EXPENSES.
Page 4 - FORM 8.010.5 – UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G
(Revised
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 |
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If yes, name: |
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Average Monthly Amount $ |
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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
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 |
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My (printed) Name Is
I am:
PETITIONER RESPONDENT
OTHER:
SIGNATURE
Page 5 - FORM 8.010.5 – UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G
(Revised
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. |
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(Other Party/Attorney name) |
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Address: |
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2. |
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(name) |
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Address: |
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SIGNATURE
Page 6 - FORM 8.010.5 – UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G
(Revised
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.
TOTAL FIXED COSTS
Page 7 - FORM 8.010.5 – UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G
(Revised
2.CONSUMER OBLIGATIONS:
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Balance |
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Name of Creditor |
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Due |
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Monthly Amount |
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A.
B.
C.
D.
E.
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TOTAL PAYMENTS ON CONSUMER OBLIGATIONS
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
OTHER:
Page 8 - FORM 8.010.5 – UNIFORM SUPPORT DECLARATION OF PETITIONER G RESPONDENT G
(Revised