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Financial Statement (Simplified) FL-155 - California
| Financial Statement (Simplified) Form. This is a California form and can be used in Family Law - Dissolution - Legal Separation -Annulment Judicial Council . |
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COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. TELEPHONE NO.: Your name and address or attorney's name and address: : Index No. : ATTORNEY FOR (Name): FL-155 FOR COURT USE ONLY Calendar No. SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: Plaintiff(s) : : : : JUDICIAL SUBPOENA -against- PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER PARENT: Defendant(s) : ...................................................... FINANCIAL STATEMENT (SIMPLIFIED) CASE NUMBER: My only source of income is TANF, SSI, or GA/GR. 1. a. I have applied for TANF, SSI, or GA/GR. b. TO 2. I am the parent of the following number of natural or adopted children from this relationship . . . . . . . . . . . . . . . . . . 3. a. The children from this relationship are with me this amount of time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. The children from this relationship are with the other parent this amount of time . . . . . . . . . . . . . . . . . . . . . . . . . . c. Our arrangement for custody and visitation is (specify, using extra sheet if necessary): THE PEOPLE OF THE STATE OF NEW YORK NOTICE: Read page 2 to find out if you qualify to use this form and how to use it. % % GREETINGS: married filing jointly head of household married filing separately. single 4. My tax filing status is: 5. My current gross income (before taxes) per month is . . . . .and excuses .being laid. aside, .you .and .each. of .you attend before .......... ........ ..... ... ... ... .. ...$ WE COMMAND YOU, that all business This the Honorable income comes from the following: at the Court Attach 1 Salary/wages: Amount before taxes per month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ copy of pay located at County of Retirement: Amount before taxes per month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ stubs for in room , on the day of , 20 , at o'clock in the noon, and at any recessed Unemployment compensation: Amount per month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ last 2 or adjourned date, to testify and give evidence as amonth . . in .this .action. on. the . . . . . . .the. . . . . . . . . . . $ witness . . . . . . . . . . . . . part of . . months here Workers' compensation: Amount per (cross out Social security: SSI Other Amount per month . . . . . . . . . . . . . . . . . . . . . . . . . . $ social Disability: Amount per month . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ security Interest income ( from bank accounts or other): Amount per month . . . . . . . . . . . . . . . . . . . . . $ numbers) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to I have no income other than as stated in this paragraph. the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a 6. I pay the following monthly expenses for the children in this case: result of your failure to comply. me to work or go to school . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Day care or preschool to allow a. Health care not paid for by insurance . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ b. c. School, education, tuition, or other special needs of the child . . . . . . . . . . . . . ., .. . . . of . . . .Justices. of .the Witness, Honorable one . . the . . . . . . . . . $ Travel expenses for visitation . . .day of . . . . . . . . . . . ., .20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ d. Court in ..... .. County, There are (specify number) other minor children of mine living with me. Their monthly expenses that I pay are . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 8. I spend the following average monthly amounts (please attach proof): a. Job-related expenses that are not paid by my employer (specify (Attorneyfor expenses onand type name below) reasons must sign above separate sheet) $ Required union dues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ b. Required retirement payments (not social security, FICA, 401k or IRA) . . . . . . . . . . . . . . .. . . . . . . . . . . . . $ c. .......... Health insurance costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Attorney(s) . . . . . . . . . . . . . . . . . . . . . . . $ d. for Child support I am paying for other minor children of mine who are not living with me . .. . . . . . . . . . . . . . . . $ e. f. Spousal support I am paying because of a court order for another relationship . . . . . . . . . . . . . . . . . . . . . . . $ rent or Monthly housing costs: mortgage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ g. If mortgage: interest payments $____________ real property taxes $____________ Office and P.O. Address my current employment 9. Information concerning my most recent employment: Employer: Address: Telephone number: My occupation: Telephone No.: Date work started: Facsimile No.: Date work stopped (if applicable): What was your gross income (before taxes) before work stopped?: Form Approved for Optional Use Judicial Council of California FL-155 [Rev. January 1, 2004] , 7. E-Mail Address: Mobile Tel. FINANCIAL STATEMENT (SIMPLIFIED) No.: Page 1 of 2 Family Code, ยง 4068(b) www.courtinfo.ca.gov American LegalNet, Inc. www.USCourtForms.com RESPONDENT/DEFENDANT: OTHER PARENT: COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. PETITIONER/PLAINTIFF: : : Index No. CASE NUMBER: Calendar No. 10. My estimate of the other party's gross monthly income (before taxes) is . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . $ 11. My current spouse's monthly income (before taxes) is . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . $ : JUDICIAL SUBPOENA Plaintiff(s) 12. Other information I want the court to know concerning child support in my case (attach extra sheet with the information). 13. I am attaching a copy of page
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