FOR COURT USE ONLY
TELEPHONE NO.:
Your name and address or attorney's name and address:
ATTORNEY FOR (Name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
CASE NUMBER:
FINANCIAL STATEMENT (SIMPLIFIED)
NOTICE: Read page 2 to find out if you qualify to use this form and how to use it.
My only source of income is TANF, SSI, or GA/GR.
I have applied for TANF, SSI, or GA/GR.
1.
b.
I am the parent of the following number of natural or adopted children from this relationship
The children from this relationship are with me this amount of time
%
The children from this relationship are with the other parent this amount of time
%
Our arrangement for custody and visitation is (specify, using extra sheet if necessary):
head of household married filing separately.married filing jointly
single
My tax filing status is:
My current gross income (before taxes) per month is
This income comes from the following:
Salary/wages: Amount before taxes per month
$
Retirement: Amount before taxes per month
Unemployment compensation: Amount per month
Workers' compensation: Amount per month
Other Amount per month SSISocial security:
Disability: Amount per month
I have no income other than as stated in this paragraph.
Day care or preschool to allow me to work or go to school
a.
Health care not paid for by insurance
b.
School, education, tuition, or other special needs of the child
c.
Travel expenses for visitation
d.
7.
other minor children of mine living with me. Their monthly expensesThere are (specify number)
that I pay are
I spend the following average monthly amounts (please attach proof):
Job-related expenses that are not paid by my employer (specify reasons for expenses on separate sheet)
a.
Required union dues
b.
Required retirement payments (not social security, FICA, 401k or IRA)
c.
Health insurance costs
d.
e.
f.
Spousal support I am paying because of a court order for another relationship
rent or
mortgage Monthly housing costs:
g.
my current employment
my most recent employment:Information concerning
Employer:
Address:
Telephone number:
My occupation:
Date work started:
FINANCIAL STATEMENT (SIMPLIFIED)
Form Approved for Optional Use
Judicial Council of California
FL-155 [Rev. January 1, 2004]
Family Code, § 4068(b)
www.courtinfo.ca.gov
$
$
$
$
$
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$
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$
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$
Child support I am paying for other minor children of mine who are not living with me
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I pay the following monthly expenses for the children in this case:
FL-155
Page 1 of 2
OTHER PARENT:
Date work stopped (if applicable): What was your gross income (before taxes) before work stopped?:
Interest income ( from bank accounts or other): Amount per month
$
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a.
2.
3.
a.
b.
c.
4.
5.
6.
8.
9.
. .. . . . . . . . . . . . . . . .
Attach 1
copy of pay
stubs for
last 2
months here
(cross out
social
security
numbers)
If mortgage: interest payments $____________ real property taxes $____________
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CASE NUMBER:
PETITIONER/PLAINTIFF:
10. My estimate of the other party's gross monthly income (before taxes) is
12. Other information I want the court to know concerning child support in my case (attach extra sheet with the information).
Date:
(SIGNATURE OF DECLARANT)
(TYPE OR PRINT NAME)
PETITIONER/PLAINTIFF
RESPONDENT/DEFENDANT
INSTRUCTIONS
Step 1: Are you eligible to use this form? If your answer is YES to any of the following questions, you may NOT
use this form:
• Are you self-employed?
Step 2: Make 2 copies of each of your pay stubs for the last two months. If you received money from other
than wages or salary, include copies of the pay stub received with that money.
Privacy notice: If you wish, you may cross out your social security number if it appears on the pay stub, other
payment notice or your tax return
Step 4: Complete this form with the required information. Type the form if possible or complete it neatly and
clearly in black ink. If you need additional room, please use plain or lined paper, 8½-by-11", and staple to this form.
Step 6: Serve a copy on the other party. Have someone other than yourself mail to the attorney for the other
party, the other party, and the local child support agency, if they are handling the case, 1 copy of this form, 1 copy
of each of your stubs for the last two months, and 1 copy of your most recent federal income tax return.
Step 7: File the original with the court. Staple this form with 1 copy of each of your pay stubs for the last two
months. Take this document and give it to the clerk of the court. Check with your local court about how to submit
your return.
Step 9: Take the copy of your latest federal income tax return to the court hearing.
It is very important that you attend the hearings scheduled for this case. If you do not attend a hearing, the
court may make an order without considering the information you want the court to consider.
FINANCIAL STATEMENT (SIMPLIFIED)
Page 2 of 2
FL-155 [Rev. January 1, 2004]
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$
• Is your spouse or former spouse asking for spousal support (alimony) or a change in spousal support?
• Are you asking for spousal support (alimony) or a change in spousal support?
• Are you asking the other party to pay your attorney fees?
• Is the other party asking you to pay his or her attorney fees?
• Do you receive money (income) from any source other than the following?
• Welfare (such as TANF, GR, or GA)
• Salary or wages
• Disability
• Unemployment
• Workers' compensation
• Social security
• Retirement
Step 3: Make 2 copies of your most recent federal income tax form.
If you are eligible to use this form and choose to do so, you do not need to complete the Income and Expense
Declaration (form FL-150). Even if you are eligible to use this form, you may choose instead to use the Income
and Expense Declaration (form FL-150).
Step 5: Make 2 copies of each side of this completed form and any attached pages.
RESPONDENT/DEFENDANT:
• Interest
13. I am attaching a copy of page 3 of form FL-150, Income and Expense Declaration showing my expenses.
OTHER PARENT:
Step 8: Keep the remaining copies of the documents for your file.
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.
11. My current spouse's monthly income (before taxes) is
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .
$
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