Oregon > Statewide > Circuit Court > Family Law > Miscellaneous
Uniform Support Affidavit (6F) - Oregon
| Uniform Support Affidavit (6F) Form. This is a Oregon form and can be used in Miscellaneous Family Law Circuit Court Statewide . |
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IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF In the Matter of: , Petitioner, AND , Respondent. ) ) ) ) ) ) ) ) ) Circuit Court No. Uniform Support Affidavit of: G Petitioner G Respondent G Co-petitioner (Child or Spousal Support Case) This form is an AFFIDAVIT (under penalty of perjury) required for support determinations. It must be signed, filed with the court, and served upon the other party (or their attorney). If no party seeks spousal support or a deviation (change) from the uniform child support guidelines, you need only complete the affidavit (pages 1 through 6) and any attachments requested on those pages. If any party seeks either spousal support or any deviation (change) from the uniform child support guidelines, you must complete not only the Affidavit (pages 1 through 6) and any attachments requested on those pages, but also the attached Schedule 1 - Monthly Expenses and Rebutting Factors Required. In addition, certain documentation MUST be attached as indicated on page 2. STATE OF OREGON County of ) ) ss. ) in the above-entitled I, , being first duly sworn under oath, depose and say that I am the matter and that the following are true to the best of my knowledge and belief: 1. 2. 3. 4. 5. 6. Your Age: Date of Birth: Residence Address: Name of Employer & Address: Occupation: Length of Employment: Children born of or adopted during this relationship: Social Security No.: File under UTCR 2.100 Title: Child living with: Name of Child Age Me Other Parent Other 7. List all people living in your household (other than children named in item 6 above): Name Age Relationship to You Monthly Income 8. List your other dependents or children not listed in items 6 or 7 above: Name Age Relationship to You Monthly Income 9. ENTER THE FOLLOWING INFORMATION FROM SCHEDULES INDICATED: A. TOTAL GROSS INCOME (From page 3, item 16.D.) : B. TOTAL EXPENSES OF CHILDREN (From Schedule 1, item 1.) : C. TOTAL MONTHLY EXPENSES (From Schedule 1, item 6.) : Page 1 - FORM 8.010.5 Uniform Support Affidavit of Petitioner G Respondent G Co-petitioner G UTCR 8.010(5), 8.010(7), 8.040(3), 8.040(4), 8.050(1), 8.050(3) (Revised 8-1-05) UTCR App. Page 22 American LegalNet, Inc. www.FormsWorkFlow.com 10. (a) Are you or your present spouse entitled to receive court-ordered child support for any children now living with you? YES G NO G If "YES," complete the following and ATTACH A COPY OF ALL SUCH CHILD SUPPORT ORDERS. Age Relation to You Support Amount Name of Child (b) 11. Are those support payments being made? YES G NO G Are you required to pay a court-ordered child support obligation for a child of yours who is not listed in item 6 above? YES G NO G If "YES," complete the following and ATTACH A COPY OF ALL SUCH CHILD SUPPORT ORDERS. Age Name of Recipient Monthly Support Amount Name of Child 12. Are you ordered to pay or entitled to receive court-ordered spousal support? YES G NO G If "YES," complete the following and ATTACH A COPY OF ALL SUCH SPOUSAL SUPPORT ORDERS. Paid By (Date or Event): Monthly Support Amount Owed To Owed Until: 13. Are you incurring child care costs on behalf of the children listed in item 6 above? YES G NO G If "YES," complete the following and attach documentation verifying the information provided below: Day-care Provider and Address Monthly (gross amount before application Cost of any tax credit or subsidy) Name of Child 14. 15. Do you receive any subsidy for such care? If so, amount $ per month. MEDICAL AND DENTAL ELECTIONS--The child support recipient may elect to require the support payor to name the child(ren) as the beneficiary on a health/dental insurance plan. If so elected, the child support may be adjusted by an amount equal to all or a portion of the cost to parent who provides the child's(ren's) portion of the health/dental insurance premium. Please choose: G G G I wish to require health/dental insurance coverage by the other party and understand that a portion of the premium may be deducted from support. I do not wish to require health/dental insurance coverage by the other party. I provide health/dental insurance through my employer; see page 4, item 18, of this schedule, for information. ATTACHMENTS REQUIRED G G G Last four (4) payroll stubs. Most recent federal and state income tax return. Copies of any and all relevant child/spousal support orders. G G OPTIONAL Child care documentation if you want this considered. Medical/dental insurance documentation. Page 2 - FORM 8.010.5 Uniform Support Affidavit of Petitioner G Respondent G Co-petitioner G UTCR 8.010(5), 8.010(7), 8.040(3), 8.040(4), 8.050(1), 8.050(3) (Revised 8-1-05) UTCR App. Page 23 American LegalNet, Inc. www.FormsWorkFlow.com (Income, Deductions and Medical/Dental Insurance) You must complete and submit the following attachments. Copies of recent: (1) federal and state income tax returns, (2) last four pay stubs, and (3) if self-employed, most recent profit and loss statement. 16. Your Monthly Gross Income: A. From Employment: If paid weekly, multiply weekly income by 4.3 to arrive at a monthly gross income and insert below. If paid every two weeks, multiple two weeks' income by 2.15 and insert below): Description Gross Hourly Wage: Average Number of Hours Worked Per Week: Gross Monthly Income: Gross Monthly Tips/Commissions/Bonuses (identify): SUBTOTAL: 16.A. B. From Self-Employment: If you own an interest in a partnership or in a closely held corporation, attach last year's Schedule K-1, and/or corporation federal income tax return: Description Gross Receipts: Expense Reimbursements: Rental Income: Royalty Income: Less Ordinary/Necessary Expenses: Plus Monthly Portion of Accelerated Component of any Depreciation Allowance or Investment Tax Credits: SUBTOTAL: 16.B. C. Other Sources of Income: (Please attach verification of any income available to you as listed below): Description Dividends: Interest Income: Trust Income: Contract Payments (less underlying debt): Annuity Income: Retirement Benefits--Pension/IRA/Keogh (nonsocial security): Social Security Income: Workers' Compensation Benefits Per Week Multiplied by 4.3 = Unemployment Benefits Per Week Multiplied by 4.3 = Disability Income: Gift or Prizes: Spousal Support: Expense Reimbursements and/or Per Diem Allowance (not listed in item B. above): ADC Benefits: FCAS (food stamps): Other (specify): SUBTOTAL: 16.C. D. Summary of Your Gross Income: Description Income from Employment (item 16.A. above): Self-Employment Income (
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