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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