San Luis Obispo — AD01

Source: https://www.slo.courts.ca.gov/documents/san-luis-obispo/ad01.pdf

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number and address):

TELEPHONE NO: FAX NO: (OPTIONAL) E-MAIL ADDRESS (OPTIONAL) ATTORNEY FOR:

SUPERIOR COURT OF SAN LUIS OBISPO COUNTY San Luis Obispo Branch

1035 Palm Street, Room 385, San Luis Obispo, CA 93408-2500 web site: www.slocourts.net

In the matter of the Adoption Petition of:

FINANCIAL STATEMENT CASE NO:
(STEPPARENT ADOPTION)

We, the undersigned declare that our gross family income as substantiated by our most recent Federal Tax Return, filed in 20____, falls into the category checked below:

ٱ $19,000 and below

ٱ $19,001-$34,999

ٱ $35,000-$49,999

ٱ $50,000 and above

We declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Dated: ___________________________ ________________________________________ Petitioner

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Parent Retaining Custody

AD01 FINANCIAL STATEMENT FC9002 Rev. May 2003 (STEPPARENT ADOPTION) Mandatory