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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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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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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