Mendocino — EM-115

Source: http://www.courts.ca.gov/documents/em115.pdf

EM-115 ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER: FOR COURT USE ONLY NAME: FIRM NAME: STREET ADDRESS: CITY: STATE: ZIP CODE: TELEPHONE NO.: FAX NO.: EMAIL ADDRESS: ATTORNEY FOR (name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME:

IN THE MATTER OF (name): Petitioner, a minor EMANCIPATION OF MINOR—INCOME AND CASE NUMBER: EXPENSE DECLARATION

1. My name and address are:

My telephone number is:

I have been living at this address since:

I live there with (name and relationship of all persons, including children):

2. My date of birth is:

3. a. I am attending school (name of school and grade): b. I am not attending school. The highest year of education I have completed is:

4. My occupation is:

5. a. I am employed. My place of employment is (name and address): I started work there on (date): b. I am not employed at the present time. I last worked from (starting month and year): to (ending month and year): My gross monthly earnings were: $

6. a. I am not receiving welfare or AFDC and I do not intend to apply for welfare or AFDC. b. I am receiving welfare or AFDC. Monthly amount received: $ c. I have applied for welfare or AFDC. d. I intend to apply for welfare or AFDC.

Judicial Council of California, courts.ca.gov EM-115, Page 1 of 2Rev. July 1, 2026, Mandatory Form Emancipation of Minor—Income and Fam. Code, § 7000 et seq. Expense Declaration

EM-115 IN THE MATTER OF (name): CASE NUMBER:

7. The average of my gross monthly earnings is: Amount a. Salary and wages, including bonuses and overtime $ b. Money received from parents or other adults assisting me $ (name and relationship): c. Other (specify source and amount): $

8. I have the following assets: Value a. Cash $ b. Checking account $ c. Savings account $ d. Stocks, bonds $ e. Vehicle (year, make, model): $ f. Other (specify): $

9. My monthly expenses are: Amount a. Rent or Mortgage $ b. Food $ c. Clothing $ d. Phone and utilities $ e. Vehicle $ (1) Loan payments $ (2) Maintenance $

I declare under penalty of perjury that the foregoing is true and correct.

Date:

Type or Print Name Signature of Petitioner

Rev. July 1, 2026 Emancipation of Minor—Income and EM-115, Page 2 of 2 Expense Declaration For your protection and privacy, please press the Clear button after you have printed the form. Print Save Clear