Uniform Support Declaration – Fill Out and Use

	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)

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)

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)