California > Judicial Council > Juvenile
Financial Declaration-Juvenile Dependency JV-132 - California
| Financial Declaration-Juvenile Dependency Form. This is a California form and can be used in Juvenile Judicial Council . |
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CONFIDENTIAL ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY JV-132 TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: CHILDREN'S NAMES: CASE NUMBER: FINANCIAL DECLARATION--JUVENILE DEPENDENCY 1. Personal Information: Name: Other names used: Relationship to Child: Address: City: Marital Status: Married Name of Spouse/Partner: Names and ages of dependents: Single Domestic partner Separated Divorced Widowed Zip: Phone: Mother Father I.D. or Driver's License Number: Date of Birth: Age: Alternate Phone: Social Security Number: Other Responsible Person (specify): Number of dependents living with you: 2. I receive (check all that apply): SNAP (food stamps) SSI SSP Medi-Cal County Relief/General Assistance CalWORKS or Tribal TANF (Temporary Assistance to Needy Families) IHSS (In-Home Supportive Services) CAPI (Case Assistance Program for Aged, Blind, and Disabled) 3. My gross monthly household income (before deductions for taxes) is less than the amount listed below: Family Size 1 2 Family Income $1,196.88 $1,615.63 Family Size 3 4 Family Income $2,034.38 $2,453.13 Family Size 5 6 Family Income $2,871.88 $3,290.63 If more than 6 people in family, add $418.75 for each extra person. 4. I have been reunified with my child(ren) under a court order attached. 5. I am receiving court-ordered reunification services. Page 1 of 3 Form Approved for Optional Use Judicial Council of California JV-132 [Rev. Feb. 26, 2013] FINANCIAL DECLARATION--JUVENILE DEPENDENCY Welfare and Institutions Code, ยงยง 903.1, 903.45(b), 903.47 www.courts.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL CHILDREN'S NAMES: RESPONSIBLE PERSON'S NAME: CASE NUMBER: JV-132 6. Employment: Your Employment Employer: Address: City and Zip Code: Type of Job: How long employed: Working now? Monthly salary: Take home pay: Phone: Employer: Address: City and Zip Code: Type of Job: How long employed: Working now? Monthly salary: Take home pay: Phone: Your Spouse/Partner's Employment If not now employed, who was your last employer? (Name, Address, City, and Zip Code): If not now employed, who was this person's last employer? (Name, Address, City, and Zip Code): Phone number of last employer: Phone number of last employer: 7. Other Monthly Income and Assets: Other Income Unemployment ............................................... $ Disability ......................................................... $ Social Security ............................................... $ Workers' Compensation ................................. $ Child Support Payments ................................ $ Foster Care Payments ................................... $ Other Income ................................................. $ Total $ Assets: What Do You Own? Cash ............................................................ $ Real Property/Equity .................................... $ Cars and Other Vehicles .............................. $ Life Insurance .............................................. $ Bank Accounts (list below) ........................... $ Stocks and Bonds ........................................ $ Business Interest ......................................... $ Other Assets ................................................ $ Total $ Name and branch of bank: Account numbers: JV-132 [Rev. Feb. 26, 2013] FINANCIAL DECLARATION--JUVENILE DEPENDENCY Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL CHILDREN'S NAMES: RESPONSIBLE PERSON'S NAME: CASE NUMBER: JV-132 8. Expenses: Monthly Household Expenses Rent or Mortgage Payment ........................... $ Car Payment ................................................. $ Gas and Car Insurance ................................. $ Public Transportation .................................... $ Utilities (Gas, Electric, Phone, Water, etc.) ........................................................................$ Food .............................................................. $ Clothing and Laundry .................................... $ Child Care ..................................................... $ Child Support Payments ............................... $ Medical Payments ......................................... $ Other Necessary Monthly Expenses ............. $ Total $ Reunification Plan: Monthly Cost of Required Services Parenting Classes ...................................... $ Substance Abuse Treatment ...................... $ Therapy/Counseling .................................... $ Medical Care/Medications ...........................$ Domestic Violence Counseling ................... $ Batterers' Intervention ................................. $ Victim Support ............................................ $ Regional Center Programs ......................... $ Transportation ............................................ $ In-Home Services ....................................... $ Other ........................................................... $ Total $ 9. Loan/Expense Payments (other than mortgage or car loan): Name of lender and type of loan/expense Monthly payment $ $ $ $ Balance owed $ $ $ $ I declare under penalty of perjury under the laws of the State of California that the above information is true and correct. Date: (TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT) FOR FINANCIAL EVALUATION OFFICER USE ONLY TOTAL INCOME TOTAL EXPENSES NET DISPOSABLE INCOME $ $ $ COST OF LEGAL SERVICES MONTHLY PAYMENT TOTAL COST ASSESSED $ $ $ The above-named responsible person is presumed unable to pay reimbursement for the cost of legal services in this proceeding and is eligible for a waiver of liability because he or she receives qualifying public benefits his or her household income falls below 125% of the current federal poverty guidelines he or she has been reunified with the child(ren) under a court order and payment of reimbursement would harm his or her ability to support the child(ren). Date: (SIGNATURE OF FINANCIAL EVALUATION OFFICER) JV-132 [Rev. Feb. 26, 2013] FINANCIAL DECLARATION--JUVENILE DEPENDENCY Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com
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