Santa Clara — JV-2020*

Source: https://santaclara.courts.ca.gov/system/files/forms/jv-2020_rem.pdf

(CONFIDENTIAL) ATTACHMENT JV-2020 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number and Address): FOR COURT USE ONLY

To keep other people from seeing what you have

TELEPHONE NUMBER: FAX NUMBER (Optional): entered, please press the EMAIL ADDRESS (Optional): Reset Form button at the end of this form when finished. ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA COURT ADDRESS: 201 North First Street, San José, CA 95113 MAILING ADDRESS: 191 North First Street CITY AND ZIP CODE: San José, CA 95113 BRANCH NAME: Juvenile Dependency CHILDREN’S NAMES:

FINANCIAL DECLARATION CASE NUMBER:
Hearing Financial Evaluation Hearing Date: RELATED CASES:

Date→ Time: Dept. THIS SECTION FOR COURT USE ONLY SUBSEQUENT FINANCIAL DECLARATION I am Requesting a Hearing for Reconsideration of my Order to Repay Attorney Fees filed on (date): My Request is Based on: Change of Financial Circumstances Financial Inability to Comply with Reunification Plan Requirements Reconsideration Hearing Date: Hearing Date→ Time: Dept.

1. Personal Information: Name: Social Security Number:

Other Names Used: I.D. or Driver’s License:

Address: Date of Birth: Age: Check here if you are In custody. Detention Center: Release Date: City: Zip Code: Phone: Alternate Phone:

2. I receive (check all that apply): Medi-Cal SNAP SSI SSP County/Relief/General Assistance IHSS (In-Home Supportive Services) CalWORKS or Tribal TANF (Tribal Temporary Assistance to Needy Families ) CAPI (Case Assistance Program for Aged, Blind and Disabled)

3. My gross monthly income (before deductions for taxes) is less than the amount listed below: If you checked box 3, circle the Family Income section that applies to your case. Family Size Family Income Family Size Family Income Family Size Family Income If more than 6 people in family, 1 $1,228.05 3 $2,092.71 5 $2,959.38 add $433.34 for 2 $1,659.38 4 $2,526.05 6 $3,392.71 each extra person.

If you checked any boxes in section 2 or 3 above, skip sections 4 through 8. Go to section 9, read and fill in the section and sign the form.

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(CONFIDENTIAL) ATTACHMENT JV-2020 CHILDREN’S NAMES: CASE NUMBER:

RESPONSIBLE PARTY’S NAME: RELATED NUMBERS:

4. Family: a. Marital Status: Single Married Divorced Separated Widowed Domestic Partner b. Name of Spouse/Partner: c. Number of Dependent Children Living with You Who are Under the Age of 18: d. Dependents’ Names and Ages:

5. Employment: Your Employment Spouse/Partner Employment If you checked “Married” or “Domestic Partner” in 4a, above, fill out this section.

Employer: Employer:

Address: Address:

City and Zip Code: Phone: City and Zip Code: Phone:

How Long Working Monthly Salary: Take Home Pay: How Long Working Monthly Salary: Take Home Pay: Employed? Now? Employed? Now?

If not now employed, who was your last employer? If not now employed, who was your last employer? (Name, Address and Zip Code) (Name, Address and Zip Code)

Phone number of last employer: Phone number of last employer:

6. Income and Assets: Other Income What do you own?

Unemployment and Disability .................. $ Cash ...................................................$ Social Security/ /SSD............................... $ Real Property/Equity ................................$ General Relief .......................................... $ Cars and Other Vehicles ..........................$ Worker’s Compensation........................... $ Life Insurance...........................................$ Child Support Payments .......................... $ Bank Accounts (list below) .......................$ Foster Care.............................................. $ Stocks and Bonds ....................................$ Other Income........................................... $ Business Interest......................................$ Total $ 0 Other Assets.............................................$ Total $ 0

Name and Branch of Bank: Account Numbers:

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(CONFIDENTIAL) ATTACHMENT JV-2020 CHILDREN’S NAMES: CASE NUMBER:

RESPONSIBLE PARTY’S NAME: RELATED NUMBERS:

7. Expenses

   List your monthly expenses Monthly cost of services required by your
   reunification plan

Rent or Mortgage Payment...................... $ (If you do not know the cost, please indicate “UK” ) Car Payment............................................ $ Parenting Classes …… ......................... $ Gas and Car Insurance............................ $ Substance Abuse Trmt .......................... $

Public Transportation............................... $ Therapy/Counseling ………………….… $_______________ Utilities (Gas, Electric, Phone, Water)...... $ Medical Care/Medications ........................$ Food....................................................... $ Domestic Violence Counseling.................$ Clothing and Laundry............................... $ Batterers’ Intervention ............................ $ Child Care................................................ $ Victim Support ..........................................$ Child Support Payments ........................ $ Regional Center Programs.......................$ Medical Expenses.................................... $ Transportation ........................................ $ Other Necessary Monthly Expenses........ $ In-Home Services .....................................$ Total $ 0 Other ........................................................$ Other ........................................................$ Total $ 0

8. Loan/Expense Payments Name of lender and type of loan/expense Monthly Payment Balance Owed $ $ $ $ $ $

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(CONFIDENTIAL) ATTACHMENT JV-2020 CHILDREN’S NAMES: CASE NUMBER:

RESPONSIBLE PARTY’S NAME: RELATED NUMBERS:

9. I, , understand that a hearing will be set to determine my ability to pay the

costs for legal services. If I do not appear at the hearing and do not pay in full the assessed costs for legal services, the court

may enter a judgment against me without further notice or order.

I understand that I have a right to a separate evidentiary hearing to determine my ability to pay the assessed fees, in the

event that I dispute the judicial officer’s order for repayment. I further understand that I am entitled to the following at that evidentiary hearing:

• The opportunity to be heard in person; • The opportunity to present witnesses and written evidence; • The opportunity to confront and cross-examine witnesses brought against me. • Disclosure of the evidence against me; • A written statement of findings of the court; • To be represented by an attorney and, if I cannot afford an attorney, to have an attorney appointed to represent me; and

I understand that at any time prior to full repayment of any fees ordered by the court that I may petition the court to modify or

vacate its previous judgment on the grounds of a change in circumstances with regard to my ability to pay the judgment.

I certify under penalty of perjury that the above information is true and correct. I understand that perjury is punishable by imprisonment; I also consent to the release of my credit information from credit reporting agencies.

Date:

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(TYPE OR PRINT NAME OF RESPONSIBLE PARTY/APPLICANT) (SIGNATURE OF RESPONSIBLE PARTY/APPLICANT)

Clerk’s Certificate of Service

I certify that I am not involved in this case. This notice of hearing was served on the responsible party by personal service mail and to counsel for the responsible party by mail pony mail at the street address listed above.

Date: Clerk, By , Deputy

FOR COURT USE ONLY

TOTAL INCOME $ FEES BASED ON UNIFORM COST MODEL $ TOTAL EXPENSES $ TOTAL FEES ASSESSED $ NET DISPOSABLE INCOME $ PAYMENT DUE TO COURT ON

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