Uniform Support Declaration – Fill Out and Use This PDF

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.

B.Other Sources of Your Monthly Income:

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

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—UNIFORM SUPPORT DECLARATION

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?

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.

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

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

Yes  No

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,:

C.*City where childcare is provided:

D.ATTACH COPIES OF PROOF OF CHILDCARE EXPENSES.

5.*YOUR PARENTING TIME

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

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.

Page 5—UNIFORM SUPPORT DECLARATION