Declaration of Income and Expenses - Utah State Courts
| | |
|Filer’s Name |
| |
|Filer’s Address |
| |
|City, State, Zip |
| |
|Phone |
| |
|Email |
|In the Juvenile Court of Utah |
|__________ Judicial District ________________ County |
|State of Utah, in the interest of: |Declaration of Income and Expenses |
|_____________________________________ |_______________________________ |
|(Minor’s Name) |Case Number |
|_____________________________________ |_______________________________ |
|(Minor’s Date of Birth) |Judge |
| | |
|A child under the age of 18 years | |
I solemnly swear or affirm that the following is true:
Income
|I was born on: |
|[ ] I have the following job(s). My employer’s name and address is: |Monthly pay before deductions: |Monthly pay after deductions: |
| |$ _____________ |$ _____________ |
| | | |
| | | |
|(If you do not have a job, write “None” in this space) | | |
|[ ] I have income from sources other than employment (include such |Source of Income |Monthly income, non-wage: |
|sources as rental income, money, or other support). | |$ _____________ |
| | | |
|[ ] I receive this much per month from government programs (Include such|Source of Income |Monthly income, from government|
|sources as social security benefits, workers’ compensation, housing, food,| |programs: |
|and other living allowances). | |$ _____________ |
|[ ] I share a household with others, some of whom have jobs and share |Monthly pay, before deductions, |Monthly pay after deductions of|
|the cost of household expenses. The names of these household members are |of others in household: |others in household: |
|listed in this box. | | |
|Name: |$ _____________ |$ _____________ |
|____________________________________ | | |
|Name: |$ _____________ |$ _____________ |
|____________________________________ | | |
Assets
|[ ] I have this much money in cash, in the bank, in stocks or bonds, and in other available sources: |$ _____________ |
|[ ] Other people or organizations owe me this much money: |$ _____________ |
[ ] I own or am buying a home, land, other real property, vehicles, other personal property, or business interests as listed below:
|Property (home, land, vehicles, etc.) and location |Balance Owed |Value |
|Home |$ _____________ |$ _____________ |
|Land and other real property |$ _____________ |$ _____________ |
|Cars, trucks, or other vehicles |$ _____________ |$ _____________ |
|Other personal property |$ _____________ |$ _____________ |
|Business interests |$ _____________ |$ _____________ |
Debt
[ ] I owe the following debts:
|To whom owed |Amount |
| |$ _____________ |
| |$ _____________ |
| |$ _____________ |
| |$ _____________ |
| |$ _____________ |
Expenses
[ ] In an average month, I spend money for the following items
| |Amount | |Amount |
|Food |$ _____________ |Water |$ _____________ |
|Clothing |$ _____________ |Telephone |$ _____________ |
|Housing |$ _____________ |Uninsured medical expenses |$ _____________ |
|Transportation |$ _____________ |Health insurance |$ _____________ |
|Electricity |$ _____________ |Child support |$ _____________ |
|Gas |$ _____________ |Education expense |$ _____________ |
|Other (list) |$ _____________ |Other (list) |$ _____________ |
|I declare under criminal penalty under the law of Utah that everything stated in this document is true. |
|Signed at ______________________________________________________ (city, and state or country). |
| |Signature ► | |
|Date |Printed Name | |
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