Financial Statement Simplified
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2FL-155
TELEPHONE NO.:
FOR COURT USE ONLY
Your name and address or attorney's name and address:
To keep other people from
seeing what you entered on
your form, please press the
Clear This Form button at the
ATTORNEY FOR (Name):
end of the form when finished.
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT:
CASE NUMBER:
FINANCIAL STATEMENT (SIMPLIFIED)
NOTICE: Read page 2 to find out if you qualify to use this form and how to use it.
a.
My only source of income is TANF, SSI, or GA/GR.
1.
I have applied for TANF, SSI, or GA/GR.
b.
2.
I am the parent of the following number of natural or adopted children from this relationship
. . . . . . . . . . . . . . . . . .
%
3. a.
The children from this relationship are with me this amount of time
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
%
b.
The children from this relationship are with the other parent this amount of time
. . . . . . . . . . . . . . . . . . . . . . . . . .
Our arrangement for custody and visitation is (specify, using extra sheet if necessary):
c.
My tax filing status is:
single
married filing jointly
head of household
married filing separately.
4.
5.
My current gross income (before taxes) per month is
$
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
This income comes from the following:
Attach 1
Salary/wages: Amount before taxes per month
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
copy of pay
$
Retirement: Amount before taxes per month
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
stubs for
$
Unemployment compensation: Amount per month
last 2
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
months here
Workers' compensation: Amount per month
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(cross out
$
Social security:
SSI
Other
Amount per month
. . . . . . . . . . . . . . . . . . . . . . . . . .
social
Disability: Amount per month
$
. . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . .
security
Interest income ( from bank accounts or other): Amount per month
. . . . . . . . . . . . . . . . . . . . .
$
numbers)
I have no income other than as stated in this paragraph.
6.
I pay the following monthly expenses for the children in this case:
$
Day care or preschool to allow me to work or go to school
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
a.
$
b.
Health care not paid for by insurance
. . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
c.
School, education, tuition, or other special needs of the child
. . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . .
$
Travel expenses for visitation
d.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.
There are (specify number)
other minor children of mine living with me. Their monthly expenses
$
that I pay are
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.
I spend the following average monthly amounts (please attach proof):
a.
Job-related expenses that are not paid by my employer (specify reasons for expenses on separate sheet)
$
Required union dues
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
b.
$
Required retirement payments (not social security, FICA, 401k or IRA)
. . . . . . . . . . . . . . .. . . . . . . . . . . . .
c.
$
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
d.
Health insurance costs
$
Child support I am paying for other minor children of mine who are not living with me
e.
. .. . . . . . . . . . . . . . . .
$
f.
Spousal support I am paying because of a court order for another relationship
. . . . . . . . . . . . . . . . . . . . . . .
$
Monthly housing costs:
rent or
mortgage
g.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If mortgage: interest payments $____________ real property taxes $____________
9.
Information concerning
my current employment
my most recent employment:
Employer:
Address:
Telephone number:
My occupation:
Date work started:
Date work stopped (if applicable):
What was your gross income (before taxes) before work stopped?:
Page 1 of 2
Form Approved for Optional Use
Family Code, § 4068(b)
FINANCIAL STATEMENT (SIMPLIFIED)
Judicial Council of California
FL-155 [Rev. January 1, 2004]
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