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FL-150 SUPERIOR COURT OF CALIFORNIA, COUNTY OF (California)

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ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):
FOR COURT USE ONLY
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
CASE NUMBER:
INCOME AND EXPENSE DECLARATION
Date:
(SIGNATURE OF DECLARANT)
Page 1 of 4
INCOME AND EXPENSE DECLARATION
Form Adopted for Mandatory Use
Judicial Council of California
FL-150 [Rev. January 1, 2007]
FL-150
Family Code, §§ 2030–2032,
2100–2113, 3552, 3620–3634,
4050–4076, 4300–4339
www.courtinfo.ca.gov
Employment 1.
Employer:
Employer's address:
Occupation:
Employer's phone number:
Number of years of college completed (specify):
I have completed high school or the equivalent:
Date job started:
If unemployed, date job ended:
I get paid
$ gross (before taxes)
I work about hours per week.
(If you have more than one job, attach an 8½-by-11-inch sheet of paper and list the same information as above for your other
jobs. Write "Question 1—Other Jobs" at the top.)
Number of years of graduate school completed (specify):
Degree(s) obtained (specify):
3. Tax information
I last filed taxes for tax year (specify year):
single head of household
married, filing separately
married, filing jointly with (specify name):
I file state tax returns in
I claim the following number of exemptions (including myself) on my taxes (specify):
This estimate is based on (explain):
I declare under penalty of perjury under the laws of the State of California that the information contained on all pages of this form and
any attachments is true and correct.
OTHER PARENT/CLAIMANT:
per month per week
California
4. Other party's income. I estimate the gross monthly income (before taxes) of the other party in this case at (specify): $
(Give information on your current job or, if you're unemployed, your most recent job.)
Age and education
2.
I have:
a.
c.
d.
My tax filing status is
other (specify state):
(If you need more space to answer any questions on this form, attach an 8½-by-11-inch sheet of paper and write the
question number before your answer.)
b.
Yes
No
b.
c.
d.
e.
Degree(s) obtained (specify):
My age is (specify):
a.
professional/occupational license(s) (specify):
vocational training (specify):
If no, highest grade completed (specify):
a.
b.
c.
d.
e.
f.
g.
h.
Attach copies
of your pay
stubs for last
two months
(black out
social
security
numbers).
per hour.
Number of pages attached:
(TYPE OR PRINT NAME)
TELEPHONE NO.:
ATTORNEY FOR (Name):
E-MAIL ADDRESS (Optional):
To keep other people from
seeing what you entered on
your form, please press the
Clear This Form button at the
end of the form when finished.
Disability: Social security (not SSI) State disability (SDI) Private insurance .
All other property,
CASE NUMBER:
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT/CLAIMANT:
Income (For average monthly, add up all the income you received in each category in the last 12 months
and divide the total by 12.)
Page 2 of 4
INCOME AND EXPENSE DECLARATION
FL-150 [Rev. January 1, 2007]
Salary or wages (gross, before taxes). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Attach copies of your pay stubs for the last two months and proof of any other income. Take a copy of your latest federal
tax return to the court hearing. (Black out your social security number on the pay stub and tax return.)
5.
a.
c.
Last month
$
$
Commissions or bonuses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
My financial situation has changed significantly over the last 12 months because (specify):
9.
Assets11.
a.
b.
Total
$
$
$
Cash and checking accounts, savings, credit union, money market, and other deposit accounts . . . . . . . . . . . . . . . .
c.
Stocks, bonds, and other assets I could easily sell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Average
monthly
Change in income.
Investment income
(Attach a schedule showing gross receipts less cash expenses for each piece of property.)
I received one-time money (lottery winnings, inheritance, etc.) in the last 12 months (specify source and
6.
7.
Rental property income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other (specify): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dividends/interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
$
8.
$
Trust income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
Additional income.
Pension/retirement fund payments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Social security retirement (not SSI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Unemployment compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workers' compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other (military BAQ, royalty payments, etc.) (specify): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
g.
h.
i.
j.
k.
l.
d.
e.
$
$
Public assistance (for example: TANF, SSI, GA/GR) currently receiving . . . . . . . . . . . . . . . . .
Spousal support from this marriage from a different marriage . . . . . . . . . . . . . . . . . .
$
$
$
$
$
$
$
b.
Overtime (gross, before taxes) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
a.
c.
d.
b.
I am the
owner/sole proprietor business partner other (specify):
Number of years in this business (specify):
Attach a profit and loss statement for the last two years or a Schedule C from your last federal tax return. Black out your
social security number. If you have more than one business, provide the information above for each of your businesses.
Name of business (specify):
Type of business (specify):
Income from self-employment, after business expenses for all businesses. . . . . . . . . . . . . . . . . . . . .
$
Deductions
10.
a.
Last month
$
$
$
$
$
Required union dues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b.
Required retirement payments (not social security, FICA, 401(k), or IRA). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medical, hospital, dental, and other health insurance premiums (total monthly amount). . . . . . . . . . . . . . . . . . . . . . . .
d.
Child support that I pay for children from other relationships. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e.
Spousal support that I pay by court order from a different marriage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
g.
$
Necessary job-related expenses not reimbursed by my employer (attach explanation labeled "Question 10g") . . . . .
Partner support from this domestic partnership from a different domestic partnership
f.
$
$
f.
Partner support that I pay by court order from a different domestic partnership . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
amount):
c.
real and personal (estimate fair market value minus the debts you owe) . . . .
FL-150
CASE NUMBER:
Name
Age
How the person is
related to me? (ex: son)
That person's gross
monthly income
Pays some of the
household expenses?
The following people live with me:
Average monthly expenses
Groceries and household supplies. . . . . . .
Rent or mortgage. . .
$
(1)
Eating out. . . . . . . . . . . . . . . . . . . . . . . . . .
If mortgage:
average principal:
Utilities (gas, electric, water, trash) . . . . . .
$
Telephone, cell phone, and e-mail . . . . . . .
average interest:
$
$
Laundry and cleaning . . . . . . . . . . . . . . . . .
$
Clothes . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
Education . . . . . . . . . . . . . . . . . . . . . . . . . .
Real property taxes . . . . . . . . . . . . . .
$
Entertainment, gifts, and vacation. . . . . . . .
$
Homeowner's or renter's insurance
(if not included above) . . . . . . . . . . . .
Auto expenses and transportation
$
$
Monthly payments listed in item 14
(itemize below in 14 and insert total here). .
Maintenance and repair . . . . . . . . . . .
$
$
Savings and investments. . . . . . . . . . . . . . .
$
$
Other (specify): . . . . . . . . . . . . . . . . . . . . . .
$
Child care . . . . . . . .. . . . . . . . . . . . . . . . . .
$
TOTAL EXPENSES (a–q) (do not add in
$
the amounts in a(1)(a) and (b))
Page 3 of 4
INCOME AND EXPENSE DECLARATION
FL-150 [Rev. January 1, 2007]
$
$
$
$
Yes No
Yes No
Yes No
Yes No
a.
b.
c.
d.
Estimated expenses Actual expenses
Proposed needs
Installment payments and debts not listed above
(insurance, gas, repairs, bus, etc.) . . . . . . .
Charitable contributions. . . . . . . . . . . . . . . .
$
Date of last payment
Amount
For
Paid to
$
$
$
$
Home:
Balance
The source of this money was (specify):
I still owe the following fees and costs to my attorney (specify total owed): $
I confirm this fee arrangement.
(SIGNATURE OF ATTORNEY)
(TYPE OR PRINT NAME OF ATTORNEY)
Attorney fees (This is required if either party is requesting attorney fees.):
To date, I have paid my attorney this amount for fees and costs (specify): $
Insurance (life, accident, etc.; do not
include auto, home, or health insurance). . .
$
My attorney's hourly rate is (specify): $
12.
13.
14.
15.
a.
b.
c.
(2)
(3)
(4)
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
e.
Yes No
$
$
$
$
Amount of expenses paid by others
$
s.
a.
b.
c.
d.
Date:
Health-care costs not paid by insurance. . .
(a)
(b)
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT/CLAIMANT:
FL-150
$
$
$
$
CASE NUMBER:
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT/CLAIMANT:
CHILD SUPPORT INFORMATION
I do not have health insurance available to me for the children through my job.
Children's health-care expenses
I do
a.
The monthly cost for the children's health insurance is or would be (specify): $
Additional expenses for the children in this case
Children's health care not covered by insurance . . . . . . . . . . . . . . . . . . . .
Travel expenses for visitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Children's educational or other special needs (specify below): . . . . . . . .
Page 4 of 4
INCOME AND EXPENSE DECLARATION
FL-150 [Rev. January 1, 2007]
Child care so I can work or get job training. . . . . . . . . . . . . . . . . . . . . . . . .
Name of insurance company:
Address of insurance company:
I have (specify number): children under the age of 18 with the other parent in this case.
The children spend percent of their time with me and percent of their time with the other parent.
(Do not include the amount your employer pays.)
Amount per month
$
Special hardships. I ask the court to consider the following special financial circumstances
Major losses not covered by insurance (examples: fire, theft, other
insured loss) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Expenses for my minor children who are from other relationships and
are living with me . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Extraordinary health expenses not included in 18b. . . . . . . . . . . . . . . . . .
(attach documentation of any item listed here, including court orders):
$
$
$
$
$
$
Amount per month
For how many months?
(NOTE: Fill out this page only if your case involves child support.)
(If you're not sure about percentage or it has not been agreed on, please describe your parenting schedule here.)
b.
a.
c.
d.
16.
17.
18.
19.
a.
b.
b.
c.
d.
a.
b.
c.
Names and ages of those children (specify):
The expenses listed in a, b, and c create an extreme financial hardship because (explain):
Other information I want the court to know concerning support in my case (specify):
20.
Number of children
Child support I receive for those children. . . . . . . . . . . . . . . . . . . . . . .
$
(1)
(3)
(2)
FL-150
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FL-150 SUPERIOR COURT OF CALIFORNIA, COUNTY OF (California)

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Completed 29 May 2022

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