Fillable IN THE CIRCUIT COURT OF THE STATE OF (Oregon)

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IN THE CIRCUIT COURT OF THE STATE OF (Oregon)

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Uniform Support Declaration
Page 1 of
2 (Aug 2019)
IN THE CIRCUIT COURT OF THE STATE OF OREGON
FOR THE COUNTY OF
Case No: ______________________
Petitioner
and
UNIFORM SUPPORT
DECLARATION
Respondent
CSP No.:____________________
Unmarried children age 18, 19, or 20 years old (per ORS 107.108)
I am the petitioner respondent other:
1. Number of children
a. Joint minor children (children of the parties together)
b. Joint adult children (age 18, 19, or 20)
i. Joint adult children attending school
unknown
c. Non-joint minor children (children of only one party)
Number of overnights the joint children spend with me (per year)
i. Current order, judgment, or written agreement
ii. Proposed
2. Sources of income
Wages/Salary: (monthly, before taxes)
$__________ per hour
________ hours/week
Subtotal A:
$
(Complete table below with monthly averages, before taxes. Explain “other” amounts)
Tips:
Bonuses/Commission:
Workers Comp:
Interest:
Social Security:
Annuity:
Unemployment:
Trust:
Disability:
Dividends:
TANF:
Other:
Other:
Other:
Other:
Other:
Expense reimbursement/per diem allowance that reduces
personal living expenses:
Subtotal B:
$
Gross monthly income TOTAL (add Subtotal A + B) $
3. Spousal/partner support
a. Received by me (from anyone) $
b. Paid by me (to anyone) $
4. Health insurance
a. Premium to cover just me $
$ 0.00
0.00
0.00
Uniform Support Declaration
Page 2 of
2 (Aug 2019)
b. Premium paid for joint children $
c. Out of pocket medical costs paid for joint children $
d. Subsidies received for health insurance costs $
e. Oregon Health Plan (or other public health insurance) yes no
5. Other
a. Union dues $
b. Social Security or Veteran’s Benefits received for children $
i. Person with disability is: child me other parent
c. Childcare expenses for joint children (12 or younger) $
i. City or ZIP where child care is provided:
ii. Does anyone else share the cost of childcare? yes no
1. Name: Amount: $
6. Rebuttal factors
(The amount of child support is based on statewide guidelines. The guideline amount can
be rebutted (challenged) under OAR 137-050-0760, click here to read the rule:
https://www.doj.state.or.us/wp-content/uploads/2017/08/050_0760.pdf
)
I am challenging the guideline amount (explain rebuttal factors):
Attachments
4 most recent pay stubs
Benefit statements
Most recent tax return
Copies of currently effective spousal/partner support, child support, and parenting time
orders or judgments
Proof of health insurance premiums and any subsidies received
Proof of out of pocket medical expenses
Proof of childcare expenses
Evidence supporting any rebuttal factors for child support
I hereby declare that the above statements are true to the best of my knowledge
and belief. I understand they are made for use as evidence in court. I understand I
am subject to penalty for perjury.
Date Signature
Name (printed)
Contact Address City, State, ZIP Contact Phone
eS/
Uniform Support Declaration – Certificate of Mailing
Page 1 of
1 (Aug 2019)
(Serve the other party and all adult children who have not filed a Waiver of Further Appearance)
Certificate of Mailing
I certify that on (date): I placed a true and complete copy of this
Declaration and Attachment (if necessary) in the United States mail to (name):
at (address):
Date Signature
Name (printed)
Uniform Support Declaration - Attachment
Page 1 of
2 (Aug 2019)
Uniform Support Declaration Attachment
You must complete this attachment if either party seeks:
spousal/partner support OR
deviation from the child support guidelines
These are the total household expenses you must pay each month for yourself only - not for others
in your household. Any other annual, quarterly, or other periodic payments should be converted to
a monthly average.
DO NOT LIST ANY EXPENSE IF IT IS DEDUCTED FROM YOUR WAGES
1. FIXED COSTS:
Description
Monthly
Amount
A. RESIDENCE:
Mortgage or Rent
Second Mortgage/Home Equity Loan
Property Taxes and Insurance (if not included in mortgage)
B. UTILITIES: (averaged over the year)
Electricity
Gas
Water/Sewer
Trash/Recycling
Telephone/Cell Phone
Cable/Internet
C. TRANSPORTATION:
Car Payments
Fuel
Bus pass/Van pool/Etc.
Other (specify):
D. INSURANCE:
Life
Automobile
Medical/Dental
Other (specify):
E. Food and Household Items
F. Unreimbursed health costs, including medications
G. Court/Agency-ordered Support Payments in other cases
TOTAL FIXED COSTS:
$ 0.00
Uniform Support Declaration - Attachment
Page 2 of
2 (Aug 2019)
2. DEBTS:
Name of Creditor
(who debt is owed to)
Balance Due Monthly Payment
TOTAL MONTHLY DEBT PAYMENTS:
Additional page attached
3. Total Fixed Costs + Monthly Debts = $
4. Other factors you want the court to consider:
0.00
$ 0.00
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IN THE CIRCUIT COURT OF THE STATE OF (Oregon)

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Completed 20 September 2021

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