Form Jd-17 - Financial Declaration printable pdf download

FINANCIAL DECLARATION

For Applicants Requesting Waiver of Sealing Fee

For Sealing of Juvenile Traffic & Court Records in

San Mateo County, California

PLEASE PRINT

Applicant’s Name: ______________________________________ Date: ____________________________

Current Mailing Address: ___________________________________________________________________

________________________________________________________________________________________

INCOME DECLARATION

Marital Status:

_____ Single/Divorced/Legally Separated

(Check One)

_____ Married/Head of Household/Widow(er) with Dependent Child

_____ Full-Time Student Living in Parental Home*

Number of Dependents Living with You: _______

Gross Monthly Income

Applicant

Spouse

Deductions

Applicant

Spouse

1. Salary/wages

12. State inc. taxes

$ …………..

(include

commissions,

13. Fed. inc. taxes

$ …………..

bonuses and

overtime.)

$ …………..

14. Social Security

$ …………..

2. Pension and

15. State Disability

retirement

$ …………..

Insurance

$ …………..

3. Social

16. Medical/other

Security

$ …………..

insurance

$ …………..

4. Disability/

17. Union and

unemp. benefits

$ …………..

other dues

$ …………..

5. Public assistance

18. Retirement and

(Welfare, AFDC

pension fund

$ …………..

payment, etc.)

$ …………..

6. Child/spousal

19. Savings plan

$ …………..

Support

$ …………..

20. Other deduc-

7. Dividends and

tions (specify)

$ …………..

Interest

$ …………..

21. TOTAL

8. Rents (gross

DEDUCTIONS

$ …………..

receipts, less

cash exp.; attach

11. T

OTAL GROSS

schedule)

MTHLY NCOME

(LINE 11)

9. Contributions to

$ …………..

$ ………….

$ …………..

21. DEDUCTIONS

from other sources

$ …………..

(Line 21)

$ …………..

10. Income from all

22.

NET MONTHLY

INCOME

other sources

(Line 11 minus

(gross receipts,

Line 21)

trust fund allotments,

$ …………..

etc.)

$ …………..

__________________________

11. TOTAL GROSS

* If student is living in parental home, report full

MTHLY INCOME

$ …………..

family income and number of dependents.

Attach a copy of your most recent Federal (Form 1040, 1040A, 1040EZ, 1040 NR) or State (Form 540, 540A,

540 NR) income tax return to this document. Applicants receiving AFDC, OASDI, and General Relief of SSI

assistance may attach a copy of the current statement of program eligibility and benefits in place of income tax

return.) This Declaration must be signed.

I declare under penalty of perjury that the foregoing, including any attachment, is true and correct and that this

declaration is executed at ___________________________________________________, California on

___________________________________.

________________________________________________

Signature of Applicant

JD-17 (FOR)

Form Jd-17 - Financial Declaration

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