Fresno — Income and Expense Declaration

Source: https://www.fresno.courts.ca.gov/system/files/general/income-and-expense-declaration.pdf

Sparse pages use OCR; original PDF remains authoritative.

Instructions For INCOME AND EXPENSE DECLARATION WHEN TO USE THIS PACKET The Income and Expense Declaration is required anytime the parties go to court regarding spousal support or attorney’s fees. In hearings regarding only child support, the parties may file Simplified Financial Statement (FL-155) instead of an Income and Expense Declaration, as long as the party is not self-employed. This packet includes an “Income and Expense Declaration” [FL-150]. An Income and Expense Declaration may also be required when completing the Declaration of Disclosure and Settlement Conference Statement. An Income and Expense Declaration must be submitted with copies of the two most recent months’ pay stubs. If you are self-employed, you must attach the last two years’ income tax returns — including Schedule C (profits and loss statements). Be sure to blacken out any social security numbers that may appear on your pay stubs or income tax returns. You should take your tax returns to court just in case the court demands them. This may save you an additional court date by avoiding the necessity to continue the hearing to a different date. There is no fee for filing the Income and Expense Declaration. Once the Income and Expense Declaration is completed, make copies for each of the parties (i.e., one for you, one for the other party, and one for DCSS if they are involved in your case). The original is filed with the court; a copy must be served on each party by having someone, other than you and over the age of 18, mail or personally serving the other party with a copy. A Proof of Service must be completed by the person who serves the Income and Expense Declaration on the other party and that Proof of Service must be filed with the court. If you have any further questions, please contact the Fresno Superior Court Self-Help Center for further assistance. This service is free. Revised 9/01/2024

FORM INSTRUCTIONS FL-150 PARTY WITHOUT ATTORNEY OR ATTORNEY, name] YOUR NAME i YOUR ADDRESS CITY, STATE, ZIP CODE CITY: YOUR TELEPHONE NUMBER STATE BAR NUMBER: STATE: FAX NO.: ZIP CODE: TELE! E-MAICADDRES' NOTE: YOU MUST WRITE YOUR NAME AND THE OTHER PARTY'S ATTORNEY FOR (name): NAME THE EXACT SAME WAY THROUGHOUT YOUR FORMS SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: 93724-2220 Fresno County Superior Court 1130 O Street,Fresno CA PETITIONER: [PARTY WHO INITIALLY OPENED CASE ___| FOR COURT USE ONLY SAMPLE ONLY DO NOT WRITE ON THIS COPY! RESPONDENT: [PERSON WHO THIS CASE WAS STARTED AGAINST | OTHER PARTY/PARENT/CLAIMANT: |THE OTHER PARENT'S NAME ] INCOME AND EXPENSE DECLARATION CASE NUMBER: COURT CASE NUMBER

1. Employment (Give information on your current job or, if you're unemployed, your most rece nt job.) FILL OUT YOUR EMPLOYER'S INFORMATION HERE. IF YOU DO NOT HAVE A JOB, GIVE THE INFORMATION FROM YOUR LAST Attach copies . Employer: . of your pay Employer's address: stubs for last | ©: Employer's phone number: two months | d. Occupation: (black out e. Date job started: Social f. If unemployed, date job ended: Security g. | work about hours per week. numbers). h. I get paid $ gross (before taxes) [__] permonth [|] JOB AND WHEN YOUR JOB ENDED (NAME OF EMPLOYER, ADDRESS, PHONE NUMBER, JOB TITLE, DATE OF EMPLOYMENT AND SALARY) perweek [| per hour. (If you have more than one job, attach an 8 1/2-by-11-inch sheet of paper and list the same information as above for your other jobs. Write Question 5 1 67 1 1 4 393 1110 101 18 88.690002 1—Other 5 1 67 1 1 5 501 1110 66 18 96.459129 Jobs at the top.)
2. Age and education TELL THE COURT ABOUT YOUR EDUCATION INCLUDING ANY DEGREES OR LICENSES YOU EARNED. a. My age is (specify): Number of years of college completed, Number of years of gradu

| have:

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| have completed high school or the equivalent:

ool completed (specify): fessional/occupational license(s) (specify): [LICENSES EARNED No [-] vocational training (specify): [JOB TRAINING COMPLETED] 3. Tax information If no, highest grade completed (spe. es ZL Dae obtained (specify): [DEGREE EARNED] [-] Degree(s) obtained (specify): [DEGREE EARNED | GRADE FINISHED FILL OUT YOUR INFORMATION FROM THE PAST YEAR YOU FILED a. [] I last filed taxes for tax year (specify year): b. My tax filing status is [] single {] head of household [-_] married, filing jointly with (specify name): c. | file state tax returns in [] California [] other (specify state): d. | claim the following number of exemptions (including myself) on my taxes (specify): {] married, filing separately TAXES. REMEMBER TO NOTE HOW YOU FILED (SINGLE, ETC.), WHERE YOU FILED, (CA, ETC.)AND HOW MANY EXEMPTIONS YOU CLAIMED (1, ETC.) Other party's income. | estimate the gross monthly income (before taxes) of the other party in this case at (specify): $ This estimate is based on (explain): HOW MUCH DO YOU THINK THE OTHER PARTY EARNS BEFORE TAXES? HOW DID YOU COME UP WITH THAT AMOUNT? IF YOU DO NOT KNOW, EXPLAIN WHY YOU DO NOT KNOW (If you need more space to answer any questions on this form, attach an 8 1/2-by-1T-inch sheet of paper and write the question number before your answer.) Number of pages attached:

| declare under penalty of perjury under the laws of the State of California that the information contained on all pages of this form and

any attachments is true and correct. Date: [TODA DATE [ PRINT YOUR NAME HERE |

» | SIGN YOUR NAME HERE _ | (TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT)

Form Adopted for Mandatory Use Judicial Council of California FL-150 [Rev. September 1, 2024] INCOME AND EXPENSE DECLARATION Family Code, §§ 2030-2032, 2100-2113, 3552, 3620-3634, 4050-4076, 4300-4339 wwnw.courts.ca.gov

FL-150 PETITIONER: [PARTY WHO INITIALLY OPENED CASE ] CASE NUMBER: RESPONDENT: [PERSON WHO THIS CASE WAS STARTED AGAINST | COURT CASE NUMBER OTHER PARTY/PARENT/CLAIMANT: [THE OTHER PARENT'S NAME ] Attach copies of your pay stubs for the last two months and proof of any other income. Take a copy of your latest federal tax return to the court hearing. (Black out your Social Security number on the pay stub and tax return.) [LIST ALL OF YOUR INCOME, BEFORE TAXES, IN THIS AREA | 5. Income (For average monthly, add up all the income you received in each category in the last 12 months and divide the total by 12.) Average Last month monthly a. Salary or wages (gross, before taxeS).........ccccccccsssessssesseseseseeseseesesscsessesessssesevacsesavsssesecscseueeaeeecaeseseseeees $ INTHIS |{ IN THIS b. Overtime (gross, before taxes). $} CoLUNM || COLUNM c. Commissions or bonuses......... . S$} LIsT || ERNE d. Public assistance (for example: TANF, SSI, GA/GR) [] currently receiving .$ wan | AMOUNT e. Spousal support [] from this marriage [] froma different marriage [] federally taxable $) peceivep YOu f. Partner support [] from this domestic partnership [_] froma different domestic partnership $| LAST RECEIVED g. Pension/retirement fund payments. .$ FROM LAST 12 h. Social Security retirement (not SSI) J$ EACH MONTHS i. Disability: [~] Social Security (not SSI) [7] State disability (SDI) | [__] Private insurance $] souRCE || FROM EACH j. Unemployment compensation $|} THAT source k. Workers' compensation _ $| APPLIES APPLIES

1. Other (military allowances, royalty payments) (specify): $
2. Investment income (Attach a schedule showing gross receipts less cash expenses for each piece of property.) a. Dividends/interest. 0.00.00... ccccccecceeseseesesecsessesesesseceeeesececseeecsecesacsceesssesacecseseceesiceeenseseesiesiesesesesenseeeneeeees : LIST ALL OF YOUR b. Rental property income Trust i : AFTER EXPENSES AND c. Trust income {BEFORE TAXES, IN THIS d. Other (specify): $ [AREA
3. Income from self-employment, after business expenses for all businesses... so seseseeceeseseseeseeesatens So !amthe [] owner/sole proprietor {_] business partner [] other sr (specify): Number of years in this business (specify): IF YOU ARE SELF-EMPLOYED, COMPLETE ° THIS SECTION AND ATTACH A TWO YEAR Name of business (specify): PROFIT & LOSS STATEMENT/SCHEDULE C Type of business (specify): FROM YOUR LAST FEDERAL TAX RETURN Attach a profit and loss statement for the last two years or a Schedule C from your last federal tax return. Black out your Social Security number. If you have more than one business, provide the information above for each of your businesses.
4. itional income. | received one-time money (lottery winnings, inheritance, etc.) in the last 12 months (specify source and amount): CHECK THIS BOX IF YOU RECEIVED A ONE-TIME SOURCE OF INCOME, (LOTTERY OR INHERITANCE) AND WRITE WHERE YOU RECEIVED THE MONEY AND THE AMOUNT
5. hange in income. My financial situation has changed significantly over the last 12 months because (specify): IF YOU HAD A MAJOR CHANGE IN INCOME IN THE PAST 12 MONTHS, STATE WHAT THE CHANGE WAS |
6. Deductions Last month A. Required UNION due... cece cece es ecsesteseescseesesecseeeescseasseevesensacacsecieecenseseceusesssesseseteesecesserecsisesecsesececeeesseeeeeenets $ [FILL OUT THIS b. Required retirement payments (not Social Security, FICA, 401(k), or IRA) SECTION IF c. Medical, hospital, dental, and other health insurance premiums (total monthly amount). oon d. Child support that | pay for children from other relationships. DEDUCTED e. Spousal support that | pay by court order from a different marriage [___] federally tax deductible FOR ANY OF f. Partner support that | pay by court order from a different domestic partnership - iste eed g. Necessary job-related expenses not reimbursed by my employer (attach explanation labeled Question 5 1 59 2 7 14 1312 1748 110 22 75.820084 10g)......... $ MONTH'S ~ [LIST WHAT YOU HAVE IN YOUR SAVINGS AND CHECKING ACCOUNTS, ANY STOCKS, BONDS, AND/OR REAL PROPERTY | PAYCHECK
7. Assets a. Cash and checking accounts, savings, credit union, money market, and other deposit ACCOUMtS sees eee $ b. Stocks, bonds, and other assets | could easily sell c. Allother property, [-] real and [-] personal (estimate fair market value minus the debts you owe)...
   Total

• Check the box if the spousal support order or judgment was executed by the parties and the court before January 1, 2019, or if a court-ordered change maintains the spousal support payments as taxable income to the recipient and tax deductible to the payor. FL-150 [Rev. September 1, 2024] INCOME AND EXPENSE DECLARATION Page 2 of 4

FL-150 CASE NUMBER. COURT CASE NUMBER PETITIONER: [PARTY WHO INITIALLY OPENED CASE | RESPONDENT: [PERSON WHO THIS CASE WAS STARTED AGAINST | OTHER PARTY/PARENT/CLAIMANT: [THE OTHER PARENT'S NAME | 12. The following people live with me: How the person is That person's gross Pays some of the Name Age related to me (ex: son) monthly income household expenses? a. [-] Yes [-] No b LIST ANYONE WHO LIVES WITH YOU (INCLUDING CHILD(REN), ROOMATES, [__] Yes CI No . FAMILY, ETC.), THEIR AGE, THEIR RELATION TO YOU, HOW MUCH THEY MAKE c. BEFORE TAXES, AND WHETHER THEY PAY ANY EXPENSES FOR THE HOME [] Yes [] No d. [-] Yes [-] No e. (J Yes [] No 13. Average monthly expenses [[ | Estimated expenses [| Actual expenses |_| Proposed needs CHECK ONE] a. Home: hf LISTALLOF aning..... cece YOUR MONTHLY (1) J Rent or [7] mortgage.......... EXPENSES [st quecesceecesreeeeeteteeeeceee If mortgage: HERE FOR THE |.....-.::00::0200> = (a) average principal: $ ITEMS LISTED jifts, and vacation... (b) average interest: $ Auto expenses and transportation (2) Real property taxes.. (insurance, gas, repairs, bus, etc.)........000.. $ (3) Homeowner's or renter's insurance . Insurance (life, accident, etc.; do not include (if not included above).. auto, home, or health insurance)................. $ . Savings and investments.... . Charitable contributions... (4) Maintenance and repaii TOTAL EXPENSES (a-q) (do not add in the amounts in a(1)(a) and (b)) . Amount of expenses paid by others $ ADD UP ALL THE Ul EXPENSES YOU LISTED FOR WRITE HOW MUCH OF THE A TOTAL TO PUT HERE EXPENSES ARE PAID BY OTHERS Amount Utilities (gas, electric, water, trash)........0.0. b. Health-care costs not paid by insurance........ = : ©. Child CAPE. eeeeeesssssssesssesssssssssssesccecceceeceeecesteen ; fiers payments Isted in tem _ here)... § d. Groceries and household supplies. Other (Speaiiyy: 5 e. Eating out f. g. Telephone, cell phone, and e-mail................. 14. Installment payments and debts not listed above Paid to For Balance

|

&. g LIST HERE ANY PAYMENTS YOU ARE MAKING FOR VEHICLE LOANS, STUDENT LOANS, MORTGAGES, CREDIT CARDS, ETC. AND THE NAME OF THE COMPANY YOU ARE PAYING. LIST HOW MUCH YOU PAY EACH MONTH, WHAT IS STILL OWED, AND THE DATE OF YOUR LAST PAYMENT. ADD UP ALL OF THE MONTHLY PAYMENT AMOUNTS AND PUT THE TOTAL IN ITEM 13. p. Date of last payment $ $ $ $ $ $ 15. Attorney fees (This information is required if either party is requesting attorney fees): ONLY COMPLETE SECTION a. To date, | have paid my attorney this amount for fees and costs (specify): $ 15. IF YOU HAD AN b. The source of this money was (specify): ATTORNEY AND WANT c. | still owe the following fees and costs to my attorney (specify total owed): $ d. My attorney's hourly rate is (specify): THE OTHER PARTY TO

| confirm this fee arrangement. PAY FOR YOUR ATTORNEY

DO NOT SIGN ON THIS PAGE UNLESS COMPLETING SECTION 15 (TYPE OR PRINT NAME OF ATTORNEY) Date: (SIGNATURE OF ATTORNEY) FL-150 [Rev. September 1, 2024] INCOME AND EXPENSE DECLARATION Page 3 of 4

FL-150 PETITIONER: [PARTY WHO INITIALLY OPENED CASE | CASE NUMBER: RESPONDENT: [PERSON WHO THIS CASE WAS STARTED AGAINST _ | COURT CASE NUMBER OTHER PARTY/PARENT/CLAIMANT: [THE OTHER PARENT'S NAME | 16. Number of children CHILD SUPPORT INFORMATION (NOTE: Fill out this page only if your case involves child support.) WRITE IN THE NUMBER OF MINOR CHILD(REN) YOU HAVE WITH THE OTHER PARENT IN THIS CASE AND HOW MUCH TIME EACH PARENT SPENDS WITH THEM. a. | have (specify number): children under the age of 18 with the other parent in this case. b. The children spend percent of their time with me and percent of their time with the other parent. (If you're not sure about percentage or it has not been agreed on, please describe your parenting schedule here.) IF YOU DO NOT KNOW A PERCENTAGE, DESCRIBE PARENTING SCHEDULE EXAMPLE: THE CHILDREN LIVE WITH ME AND ARE WITH THE OTHER PARENT EVERY 1ST AND 3RD WEEKEND FROM FRIDAY AT 6PM TO SUNDAY AT 6M 17. Children's health-care expenses a [|] ldo ([_] Idono have health insurance available to me for the children through my job. b. Name of insurance company: CHECK WHETHER YOU DO OR DO NOT HAVE HE; c. Address of insurance company: <———|COMPANY AND HOW MUCH YOU PAY, NOT HOW -ALTH INSURANCE FOR THE CHILDREN. IF YOU DO HAVE HEALTH INSURANCE, WRITE THE NAME AND ADDRESS OF THE INSURANCE. MUCH YOUR EMPLOYER PAYS d. The monthly cost for the children's health insurance is or would be (specify): $ (Do not include the amount your employer pays.) 18. Additional expense for the children in this case a. Childcare so | can work or get job traiming..........cccccccccecceeseseeeeecsesestetseeesestecesseeeseee b. Children's health care not covered by insurance c. Travel expenses for visitation d 19. Special hardships. | ask the court to consider the following special financial circumstances Amount per month \ WRITE IN <__| ANY OTHER é EXPENSES IF 7 IT APPLIES FILL IN ITEMS a. - c. AND DESCRIBE THE HARDSHIP BELOW (attach documentation of any item listed here, including court orders): Amount per month | For how many months? a. Extraordinary health expenses not included in 18D...........:::ccccccceeeeeeeeeee $ b. Major losses not covered by insurance (examples: fire, theft, other 5 insured loss) c. (1) Expenses for my minor children who are from other relationships and are living With MO... ccc cceeeeseeeseecseseeeeseseseteseseseenseseeeseieeeesneeeteneee $ (2) Names and ages of those children (specify): (3) Child support | receive for those Children............cccccceeeseeeeeseteeeteteeeeees $ The expenses listed in a, b, and c create an extreme financial hardship because (explain): Al EXPLAIN WHY THESE EXPENSES CREATE N EXTREME FINANCIAL HARDSHIP 20. Other information | want the court to know concerning support in my case (specify): [WRITE ANY INFORMATION HERE YOU WANT THE COURT TO KNOW REGARDING CHILD SUPPORT IN THIS CASE] FL-150 [Rev. September 1, 2024] INCOME AND EXPENSE DECLARATION

FL-150 PARTY WITHOUT ATTORNEY OR ATTORNEY. STATE BAR NUMBER: FOR COURT USE ONLY NAME; FIRM NAME: STREET ADDRESS: CITY: STATE: ZIP CODE: TELEPHONE NO.: FAX NO. E-MAIL ADDRESS: ATTORNEY FOR (name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PETITIONER: RESPONDENT: OTHER PARTY/PARENT/CLAIMANT: INCOME AND EXPENSE DECLARATION CASE NUMBER

1. Employment (Give information on your current job or, if you're unemployed, your most recent job.) Attach copies a Employer: of your pay b. Employer's address: stubs for last | ©: Employer's phone number: two months d. Occupation: (black out e. Date job started: Social f. If unemployed, date job ended: Security g. | work about hours per week. numbers). h. I get paid $ gross (before taxes) [] permonth [] perweek [__] perhour. (If you have more than one job, attach an 8 1/2-by-11-inch sheet of paper and list the same information as above for your other jobs. Write Question 5 1 12 1 2 4 397 1111 100 18 92.275459 1—Other 5 1 12 1 2 5 504 1111 65 18 95.844574 Jobs at the top.)
2. Age and education a. My age is (specify): b. Ihave completed high school or the equivalent! [|] Yes [-] No If no, highest grade completed (specify): c. Number of years of college completed (specify): {] Degree(s) obtained (specify): d. Number of years of graduate school completed (specify): {_] Degree(s) obtained (specify): e. Ihave: [] professional/occupational license(s) (specify): {-_] vocational training (specify):
3. Tax information a. [] I last filed taxes for tax year (specify year): b. My tax filing status is [] single [-] head ofhousehold [—] married, filing separately [] married, filing jointly with (specify name): c. | file state taxreturnsin [—_] California [] other (specify state): d. | claim the following number of exemptions (including myself) on my taxes (specify):
4. Other party's income. | estimate the gross monthly income (before taxes) of the other party in this case at (specify): $ This estimate is based on (explain): (If you need more space to answer any questions on this form, attach an 8 1/2-by-11-inch sheet of paper and write the question number before your answer.) Number of pages attached:

| declare under penalty of perjury under the laws of the State of California that the information contained on all pages of this form and

any attachments is true and correct. Date: (TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT)

Form Adopted for Mandatory Use INCOME AND EXPENSE DECLARATION Family Code, §§ 2030-2032, 2100-2113, Judicial Council of California 3552, 3620-3634, 4050-4076, 4300-4339 FL-150 [Rev. September 1, 2024] www. courts.ca.gov

FL-150 PETITIONER: CASE NUMBER: RESPONDENT: OTHER PARTY/PARENT/CLAIMANT: Attach copies of your pay stubs for the last two months and proof of any other income. Take a copy of your latest federal tax return to the court hearing. (Black out your Social Security number on the pay stub and tax return.) 5. Income (For average monthly, add up all the income you received in each category in the last 12 months and divide the total by 12.) Salary or wages (gross, before taxes)... Overtime (gross, before taxes Commissions or bonuses. Public assistance (for example: TANF, SSI, GA/GR) [] currently receiving Spousal support ["] from this marriage [—] froma different marriage [| federally taxable* Partner support [] from this domestic partnership [] from a different domestic partnership Pension/retirement fund payments.. Social Security retirement (not SSI) : Disability: [7] Social Security (not SSI) [] State disability (SDI) | [—] Private insurance Unemployment compensation Workers' compensation Other (military allowances, royalty payments) (specify): Average Last month monthly xT saereaorD PAP PHPHAAHH HHH 6. Investment income (Attach a schedule showing gross receipts less cash expenses for each piece of property.) a. Dividends/interest..........0.ccccccc cece cscs cecseeeeeesecseeseuesecseescececsescecssesieevsnessieacssececevscecscesaueeseceeesesenesenececes b. Rental property income c. Trust income. d. Other (specify): 7. Income from self-employment, after business expenses for all businesses... cece $ lamthe [] owner/sole proprietor [] business partner {] other (specify): Number of years in this business (specify): Name of business (specify): Type of business (specify): Attach a profit and loss statement for the last two years or a Schedule C from your last federal tax return. Black out your Social Security number. If you have more than one business, provide the information above for each of your businesses. 8. [] Additional income. | received one-time money (lottery winnings, inheritance, etc.) in the last 12 months (specify source and amount): 9. [] Change in income. My financial situation has changed significantly over the last 12 months because (specify): 10. Deductions Last month A. Required UMION CUOS........eecccesesessesessesessesssseseseescensvenesuenesuenecuevenesesesussesucsesueacenessanessassucseasusucacsesnsacscsneeeaeseeeeesaens .$ b. Required retirement payments (not Social Security, FICA, 401(k), or IRA) c. Medical, hospital, dental, and other health insurance premiums (total monthly amount, d. Child support that | pay for children from other relationships. e. Spousal support that | pay by court order from a different marriage [__] federally tax deductible f. Partner support that | pay by court order from a different domestic partnership : g. Necessary job-related expenses not reimbursed by my employer (attach explanation labeled Question 5 1 24 1 8 14 1311 1748 108 23 17.903833 109’)......... 5 1 24 1 8 15 1426 1745 9 19 82.052879 $ 4 1 24 1 9 0 138 1802 1359 29 -1 5 1 24 1 9 1 138 1802 29 18 96.222023 11. 5 1 24 1 9 2 175 1804 77 17 96.768158 Assets 5 1 24 1 9 3 1445 1814 52 17 96.493393 Total 4 1 24 1 10 0 174 1837 1261 24 -1 5 1 24 1 10 1 174 1843 17 13 95.878693 a. 5 1 24 1 10 2 214 1838 52 18 96.628181 Cash 5 1 24 1 10 3 275 1839 36 17 96.496834 and 5 1 24 1 10 4 320 1839 93 22 96.756165 checking 5 1 24 1 10 5 423 1840 99 20 96.610886 accounts, 5 1 24 1 10 6 532 1839 85 22 96.962708 savings, 5 1 24 1 10 7 626 1839 57 18 97.016487 credit 5 1 24 1 10 8 692 1839 61 21 96.600266 union, 5 1 24 1 10 9 764 1844 68 17 96.488968 money 5 1 24 1 10 10 842 1839 76 21 96.770164 market, 5 1 24 1 10 11 928 1839 37 18 96.405075 and 5 1 24 1 10 12 975 1839 52 18 96.780746 other 5 1 24 1 10 13 1035 1839 76 22 93.281906 deposit 5 1 24 1 10 14 1119 1840 298 17 0.000000 ACCOUNES............ccccceeeeeeees 5 1 24 1 10 15 1426 1837 9 19 92.666718 $ 2 1 25 0 0 0 742 1869 693 20 -1 3 1 25 1 0 0 742 1869 693 20 -1 4 1 25 1 1 0 742 1869 693 20 -1 5 1 25 1 1 1 742 1869 693 20 95.000000 2 1 26 0 0 0 175 1871 1211 57 -1 3 1 26 1 0 0 175 1871 1211 57 -1 4 1 26 1 1 0 175 1871 564 23 -1 5 1 26 1 1 1 175 1871 17 18 89.166283 b. 5 1 26 1 1 2 215 1871 73 21 96.630219 Stocks, 5 1 26 1 1 3 298 1871 68 21 96.786674 bonds, 5 1 26 1 1 4 376 1872 38 17 96.580338 and 5 1 26 1 1 5 424 1872 53 17 95.804390 other 5 1 26 1 1 6 484 1873 68 16 95.804390 assets 5 1 26 1 1 7 562 1872 3 17 96.162384 | 5 1 26 1 1 8 574 1872 54 17 96.805908 could 5 1 26 1 1 9 638 1872 59 22 96.705666 easily 5 1 26 1 1 10 706 1872 33 17 96.679848 sell 4 1 26 1 2 0 175 1903 1211 25 -1 5 1 26 1 2 1 175 1909 16 13 90.662598 c. 5 1 26 1 2 2 214 1905 86 17 92.111031 Allother 5 1 26 1 2 3 308 1906 90 21 93.275337 property, 5 1 26 1 2 4 420 1903 48 25 34.210888 [] 5 1 26 1 2 5 484 1905 37 18 83.511848 real 5 1 26 1 2 6 551 1905 37 18 83.511848 and 5 1 26 1 2 7 639 1903 48 25 34.337597 {] 5 1 26 1 2 8 702 1905 89 22 91.110580 personal 5 1 26 1 2 9 829 1905 96 22 73.416107 (estimate 5 1 26 1 2 10 933 1905 34 18 96.574883 fair 5 1 26 1 2 11 973 1905 72 18 96.954018 market 5 1 26 1 2 12 1053 1905 55 18 96.889854 value 5 1 26 1 2 13 1116 1905 63 18 96.900108 minus 5 1 26 1 2 14 1187 1905 32 18 96.785591 the 5 1 26 1 2 15 1227 1905 57 18 96.631966 debts 5 1 26 1 2 16 1291 1910 39 17 96.994461 you 5 1 26 1 2 17 1338 1905 48 22 96.931602 owe) 2 1 27 0 0 0 1389 1902 46 21 -1 3 1 27 1 0 0 1389 1902 46 21 -1 4 1 27 1 1 0 1389 1902 46 21 -1 5 1 27 1 1 1 1389 1902 46 21 95.000000 2 1 28 0 0 0 138 1960 1428 49 -1 3 1 28 1 0 0 138 1960 1428 49 -1 4 1 28 1 1 0 138 1960 1428 22 -1 5 1 28 1 1 1 138 1960 7 7 93.214844 * 5 1 28 1 1 2 154 1962 59 15 95.647606 Check 5 1 28 1 1 3 220 1962 28 15 97.003708 the 5 1 28 1 1 4 256 1962 32 15 96.655342 box 5 1 28 1 1 5 296 1962 9 15 95.225739 if 5 1 28 1 1 6 311 1962 27 16 95.225739 the 5 1 28 1 1 7 346 1962 73 20 96.909668 spousal 5 1 28 1 1 8 427 1963 69 19 96.790863 support 5 1 28 1 1

960 1428 49 -1 4 1 28 1 1 0 138 1960 1428 22 -1 5 1 28 1 1 1 138 1960 7 7 93.214844 * 5 1 28 1 1 2 154 1962 59 15 95.647606 Check 5 1 28 1 1 3 220 1962 28 15 97.003708 the 5 1 28 1 1 4 256 1962 32 15 96.655342 box 5 1 28 1 1 5 296 1962 9 15 95.225739 if 5 1 28 1 1 6 311 1962 27 16 95.225739 the 5 1 28 1 1 7 346 1962 73 20 96.909668 spousal 5 1 28 1 1 8 427 1963 69 19 96.790863 support 5 1 28 1 1 9 503 1962 50 16 96.659676 order 5 1 28 1 1 10 560 1966 17 12 96.538162 or 5 1 28 1 1 11 583 1962 87 20 96.538162 judgment 5 1 28 1 1 12 677 1966 36 12 96.864769 was 5 1 28 1 1 13 721 1962 84 16 96.881569 executed 5 1 28 1 1 14 813 1962 20 20 96.460899 by 5 1 28 1 1 15 841 1963 27 15 96.830399 the 5 1 28 1 1 16 877 1962 62 20 96.998672 parties 5 1 28 1 1 17 947 1962 33 16 96.879654 and 5 1 28 1 1 18 988 1962 27 16 96.917854 the 5 1 28 1 1 19 1023 1963 45 15 96.805298 court 5 1 28 1 1 20 1076 1962 58 16 96.609657 before 5 1 28 1 1 21 1142 1962 75 20 96.609657 January 5 1 28 1 1 22 1226 1962 13 18 96.771416 1, 5 1 28 1 1 23 1248 1962 51 19 96.737038 2019, 5 1 28 1 1 24 1308 1966 18 12 96.918541 or 5 1 28 1 1 25 1333 1962 10 16 95.934944 if 5 1 28 1 1 26 1354 1967 5 11 95.934944 a 5 1 28 1 1 27 1367 1962 122 16 96.007202 court-ordered 5 1 28 1 1 28 1498 1962 68 20 96.868690 change 4 1 28 1 2 0 138 1989 998 20 -1 5 1 28 1 2 1 138 1989 90 15 96.539154 maintains 5 1 28 1 2 2 235 1989 28 15 96.868469 the 5 1 28 1 2 3 270 1989 69 19 96.941193 spousal 5 1 28 1 2 4 348 1990 71 18 96.840927 support 5 1 28 1 2 5 427 1990 89 19 96.530060 payments 5 1 28 1 2 6 524 1993 21 12 96.913406 as 5 1 28 1 2 7 553 1989 67 16 96.936340 taxable 5 1 28 1 2 8 628 1989 66 16 96.280136 income 5 1 28 1 2 9 701 1990 16 15 96.983566 to 5 1 28 1 2 10 725 1989 27 16 96.818901 the 5 1 28 1 2 11 761 1989 78 20 96.937103 recipient 5 1 28 1 2 12 846 1989 33 16 96.713799 and 5 1 28 1 2 13 887 1990 28 15 96.604912 tax 5 1 28 1 2 14 922 1989 95 16 96.604912 deductible 5 1 28 1 2 15 1024 1990 16 15 96.999191 to 5 1 28 1 2 16 1047 1989 29 16 96.987030 the 5 1 28 1 2 17 1084 1993 52 16 95.600456 payor. 2 1 29 0 0 0 133 2028 1435 2 -1 3 1 29 1 0 0 133 2028 1435 2 -1 4 1 29 1 1 0 133 2028 1435 2 -1 5 1 29 1 1 1 133 2028 1435 2 95.000000 2 1 30 0 0 0 135 2040 1433 19 -1 3 1 30 1 0 0 135 2040 1433 19 -1 4 1 30 1 1 0 135 2040 1433 19 -1 5 1 30 1 1 1 135 2043 50 11 91.893700 FL-150 5 1 30 1 1 2 191 2043 31 14 78.960251 [Rev. 5 1 30 1 1 3 233 2043 90 14 96.626221 September 5 1 30 1 1 4 313 2026 13 39 96.350060 1, 5 1 30 1 1 5 330 2043 39 15 73.507195 2024) 5 1 30 1 1 6 632 2040 93 19 96.177544 INCOME 5 1 30 1 1 7 733 2041 51 17 96.177544 AND 5 1 30 1 1 8 793 2041 110 17 96.380341 EXPENSE 5 1 30 1 1 9 913 2040 169 18 96.253532 DECLARATION 5 1 30 1 1 10 1484 2041 36 15 94.981537 Page 5 1 30 1 1 11 1527 2041 7 12 93.309143 2 5 1 30 1 1 12 1540 2041 28 12 93.309143 of 5 1 30 1 1 13 1563 2028 8 40 96.830612 4

FL-150 PETITIONER: CASE NUMBER: RESPONDENT: OTHER PARTY/PARENT/CLAIMANT: 12. The following people live with me: How the person is That person's gross Pays some of the Name Age related to me (ex: son) | monthly income household expenses? a. [--{] Yes [-] No b. (J Yes [__] No Cc. [--] Yes [-] No d. (J Yes [] No e. [J] Yes [] No 13. Average monthly expenses [| Estimated expenses [] Actual expenses [] Proposed needs a. Home: h. Laundry and cleaning .$ (1) J Rent or [-] mortgage.......... $ i. Clothes $ If mortgage: j. Education $ (a) average principal: $ k. Entertainment, gifts, and vacation .$ (b) average interest: $ 1. Auto expenses and transportation (2) Real property taxes.. (insurance, gas, repairs, bus, etc.)......0.0. $ (3) Homeowner's or renter's insurance “ m. Insurance (life, accident, etc.; do not include (if not included ADOVE)..........ccccceeeeeeeeeee auto, home, or health insurance). $ (4) Maintenance and repair. n. Savings and investments. $ 0. Charitable contributions. p. Monthly payments listed in item 14 Health-care costs not paid by insurance b. ©. Child care (itemize below in 14 and insert total here)... $ d. Groceries and household supplies................. $ g. Other (specify): e. Eating out. : f. Utilities (gas, electric, water, trash). r tho amounts inca) ant (by) add in $ g. Telephone, cell phone, and e-mail. s. Amount of expenses paid by others $ 14. Installment payments and debts not listed above Paid to For Amount Balance Date of last payment $ $ $ $ $ $ $ $ $ $ $ $ 15. Attorney fees (This information is required if either party is requesting attorney fees): a. To date, | have paid my attorney this amount for fees and costs (specify): $ b. The source of this money was (specify): c. | still owe the following fees and costs to my attorney (specify total owed): $ d. My attorney's hourly rate is (specify):

| confirm this fee arrangement.

Date: » (TYPE OR PRINT NAME OF ATTORNEY) (SIGNATURE OF ATTORNEY) FL-180 [Rev. September 1, 2024] INCOME AND EXPENSE DECLARATION Page 3 of 4

FL-150 PETITIONER: CASE NUMBER: RESPONDENT. OTHER PARTY/PARENT/CLAIMANT: CHILD SUPPORT INFORMATION (NOTE: Fill out this page only if your case involves child support.) 16. Number of children a. b

| have (specify number): children under the age of 18 with the other parent in this case.

. The children spend percent of their time with me and percent of their time with the other parent. (If you're not sure about percentage or it has not been agreed on, please describe your parenting schedule here.) 17. Children's health-care expenses a b c d 18. Additional expense for the children in this case a. b. c. d . [J] Ido [-_] Ido not have health insurance available to me for the children through my job. . Name of insurance company: . Address of insurance company: . The monthly cost for the children's health insurance is or would be (specify): $ (Do not include the amount your employer pays.) Amount per month Childcare so | can work or get job training..... Children's health care not covered by insurance Travel expenses for visitation...........000cccecee 19. Special hardships. | ask the court to consider the following special financial circumstances (attach documentation of any item listed here, including court orders): Amount per month — For how many months? a. Extraordinary health expenses not included in 18b............0.c:ccececeeeeetee $ b. Major losses not covered by insurance (examples: fire, theft, other INSU 1OSS) oo. eccecescccscseseseseseeeseseseseseseseteeseueseiessscsesusuessnsestensesseseeeceeee $ c. (1) Expenses for my minor children who are from other relationships and are living with me $ (2) Names and ages of those children (specify) (3) Child support | receive for those Children... cceeeeeseeseteteeeeeteneeeees $ The expenses listed in a, b, and c create an extreme financial hardship because (explain): 20. Other information | want the court to know concerning support in my case (specify): FL-150 [Rev. September 1, 2024] INCOME AND EXPENSE DECLARATION Page 4 of 4