Uniform Income & Expense Statement Page 4

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Do you have court ordered counseling or classes that you must attend?  Yes  No
$
If yes, what are your expenses associated with these classes?
Do you have a medical condition that prevents you from working?  Yes  No
Attach proof of disability (SSA award letter, doctor’s diagnosis of disability).
Do you have court or attorney fees associated with the children in care?  Yes  No
If yes, list the fees:
Do you have to pay probation fees?  Yes  No If yes, how much? $
Are there any additional expenses or needs you want us to consider when calculating your child
support?
Amount of the expense: $
How does it affect your ability to pay support?
Are there any other special circumstances that you want us to consider?
Is there any information you can provide about the other parent?
If you need more room to answer any of these questions, attach a separate piece of paper.
 Yes  No
Are you represented by an attorney for child support matters?
If yes, please provide the attorney name and contact information below.
Attorney Name
Phone #
Fax #
Address
City/State
Zip
The Child Support Program can provide you with information from forms and other notices in your
own language free of charge. This also includes Braille, large print, and the use of interpreters. To find
out more, contact your child support office.
The Child Support Program (CSP) provides services for the State of Oregon. We cannot represent
you or give you legal advice. You may contact your own lawyer at any time. Low cost legal services may
be available. For information, you may visit the CSP website at oregonchildsupport.gov.
Division of Child Support
`
` ` `
Telephone: `
FAX: `
TTY: (800) 735-2900
Page 4 of 4 - UNIFORM INCOME & EXPENSE STATEMENT
CSF 01 0100 (Rev. 04/18/14) CSCM Initials CSP#:

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