Form Fl-320 - Responsive Declaration To Request For Order - Superior Court Of Stanislaus County Page 16
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17FL-150
CASE NUMBER:
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT/CLAIMANT:
12.
The following people live with me:
How the person is
That person's gross
Pays some of the
Name
Age
related to me? (ex: son)
monthly income
household expenses?
a.
Yes
No
b.
Yes
No
c.
Yes
No
d.
Yes
No
e.
Yes
No
13.
Average monthly expenses
Estimated expenses
Actual expenses
Proposed needs
a.
Home:
h.
Laundry and cleaning
. . . . . . . . . . . . . .
$
(1)
Rent or
mortgage
. . . . . . .
$
i.
Clothes
. . . . . . . . . . . . . . . . . . . . . . . . .
$
If mortgage:
j.
Education
$
. . . . . . . . . . . . . . . . . . . . .
(a)
average principal:
$
(b)
average interest:
$
k.
Entertainment, gifts, and vacation
. . . . .
$
(2)
Real property taxes
. . . . . . . . . . . . . . . .
$
l.
Auto expenses and transportation
(3)
(insurance, gas, repairs, bus, etc.)
. . . . .
$
Homeowner's or renter's insurance
(if not included above)
. . . . . . . . . . . . . .
$
m.
Insurance (life, accident, etc.; do not
include auto, home, or health insurance) $
(4)
Maintenance and repair
. . . . . . . . . . . .
$
n.
Savings and investments
. . . . . . . . . . . .
$
b.
Health-care costs not paid by insurance
. . .
$
o.
Charitable contributions
. . . . . . . . . . . . . .
$
p.
Monthly payments listed in item 14
c.
Child care
. . . . . . . . . . . . . . . . . . . . . . . . . . .
$
(itemize below in 14 and insert total here)
$
d.
Groceries and household supplies
. . . . . . . .
$
q.
Other (specify):
. . . . . . . . . . . . . . . . . . . . .
$
e.
Eating out
. . . . . . . . . . . . . . . . . . . . . . . . . . .
$
r.
TOTAL EXPENSES (a–q) (do not add in
f.
Utilities (gas, electric, water, trash)
. . . . . . .
$
the amounts in a(1)(a) and (b))
$
g.
Telephone, cell phone, and e-mail
. . . . . . .
$
s.
Amount of expenses paid by others
$
14.
Installment payments and debts not listed above
Paid to
For
Amount
Balance
Date of last payment
$
$
$
$
$
$
$
$
$
$
$
$
15.
Attorney fees (This is required if either party is requesting attorney fees.):
a.
To date, I have paid my attorney this amount for fees and costs (specify): $
b.
The source of this money was (specify):
c.
I still owe the following fees and costs to my attorney (specify total owed): $
d.
My attorney's hourly rate is (specify): $
I confirm this fee arrangement.
Date:
NAME:
(TYPE OR PRINT NAME OF ATTORNEY)
(SIGNATURE OF ATTORNEY)
FL-150 [Rev. January 1, 2007]
Page 3 of 4
INCOME AND EXPENSE DECLARATION
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