Butte — GR.050

Source: https://www.butte.courts.ca.gov/system/files/local-rules/gr050-financial-information-ad-1125.pdf

SUPERIOR COURT OF CALIFORNIA, COUNTY OF BUTTE RULES

(if applicable): FINANCIAL INFORMATION Court Use Only
Approved

Denied

IN RE: Initials ___________ CASE NUMBER:

PARTY INFORMATION

Full Name: Date of birth: Telephone:

Residence Address: (City) (State) (Zip Code)

Mailing Address (if different from above): (City) (State) (Zip Code)

Social Security Number: Driver’s License Number:

Marital Status: Single Married Divorced Separated Widowed

Spouse’s Name: Number of Children under 18: Ages:

Are the children in the home? Yes No

I receive (pick all that apply):

Food stamps Supp. Sec. Inc. SSP Medi-Cal County Relief/Gen. Assist. IHSS Cal WORKS or Tribal TANF

CAPI WIC Unemployment

My gross monthly household income (before deductions for taxes) is less than the amount listed below.

Family Size Family Income Family Size Family Income Family Size Family Income If more than 6 people are at 1 $2,510.00 3 $4,303.34 5 $6,096.67 home, add $896.67 2 $3,406.67 4 $5,200.00 6 $6,993.34 for each extra person.

Employment and Income Monthly Expenses

Currently, Employed? Yes No Rent/House Payment: $

Receiving Unemployment Yes No Amt. $ Utilities & Telephone: $

Receiving Social Security Yes No Amt. $ Monthly Food & Household Expenses: $

Gross Salary per Month: $ Monthly Medical/Dental Expenses: $

Total Monthly Deductions: $ Transportation, gas, repair, insurance: $

Net Salary per month (after taxes): $ Clothing/Laundry: $

Other Income (List Source & Amount): $ Child, Spousal Support: $

$ Other Court fines: $

Child Support: $ School, Child Care: $

Installment payments: $

$

Total Monthly Income: $ Total Monthly Expenses: $

---

(GR.050) Page 1 of 2 (A.D. 1-1-25) Mandatory FINANCIAL INFORMATION

Spouse/Other Employment and Income Assets (List Current Value)

Currently, Employed? Yes No Real Estate (value): $ Balance on Mortgage: $

Receiving Unemployment Yes No Amt. $ Real Estate (value): $ Balance on Mortgage: $

Receiving Social Security Yes No Amt. $ Vehicle/boat (value): $

Gross Salary per Month: $ Make: Model:

Total Monthly Deductions: $ Vehicle/boat (value): $

Net Salary per month (after taxes): $ Make: Model:

Other Income (List Source & Amount): $ Other assets: $ $

$ S $

Child Support: $ Checking/Savings Account(s): $

Total Monthly Income: $ Bank: Branch:

Checking/Savings Account(s): $

Bank: Branch:

Net Assets (Assets – Liabilities): $

I certify that the foregoing is a complete and accurate statement of my financial situation and that I have no other additional income or assets whatsoever. You have my express permission to verify the information I have furnished. I declare under penalty of perjury that the foregoing is true and correct.

SIGN
________________________________ _______________________________________________
(Date) (Signature of Party or Party’s Attorney)

---

(GR.050) Page 2 of 2 (A.D. 1-1-25) Mandatory FINANCIAL INFORMATION