Income And Expense Declaration Page 4

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FL-150
CASE NUMBER:
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT/CLAIMANT:
CHILD SUPPORT INFORMATION
(NOTE: Fill out this page only if your case involves child support.)
16.
Number of children
a.
I have (specify number):
children under the age of 18 with the other parent in this case.
b.
The children spend
percent of their time with me and
percent of their time with the other parent.
(If you're not sure about percentage or it has not been agreed on, please describe your parenting schedule here.)
17.
Children's health-care expenses
I do not
have health insurance available to me for the children through my job.
I do
a.
b.
Name of insurance company:
c.
Address of insurance company:
d.
The monthly cost for the children's health insurance is or would be (specify): $
(Do not include the amount your employer pays.)
Additional expenses for the children in this case
Amount per month
18.
a.
Child care so I can work or get job training. . . . . . . . . . . . . . . . . . . . . . . . .
$
Children's health care not covered by insurance . . . . . . . . . . . . . . . . . . . .
b.
$
$
c.
Travel expenses for visitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
d.
Children's educational or other special needs (specify below): . . . . . . . .
Special hardships. I ask the court to consider the following special financial circumstances
19.
(attach documentation of any item listed here, including court orders):
Amount per month
For how many months?
Extraordinary health expenses not included in 18b. . . . . . . . . . . . . . . . . .
a.
$
b.
Major losses not covered by insurance (examples: fire, theft, other
$
insured loss) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(1)
c.
Expenses for my minor children who are from other relationships and
$
are living with me . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(2)
Names and ages of those children (specify):
$
(3)
Child support I receive for those children. . . . . . . . . . . . . . . . . . . . . . .
The expenses listed in a, b, and c create an extreme financial hardship because (explain):
20.
Other information I want the court to know concerning support in my case (specify):
FL-150 [Rev. January 1, 2007]
Page 4 of 4
INCOME AND EXPENSE DECLARATION

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