Form JV-132 Financial Declaration - Juvenile Dependency - California

Form JV-132 is a California Courts form also known as the "Financial Declaration - Juvenile Dependency". The latest edition of the form was released in March 2, 2018 and is available for digital filing.

Download an up-to-date Form JV-132 in PDF-format down below or look it up on the California Courts Forms website.

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CONFIDENTIAL
JV-132
ATTORNEY OR PARTY WITHOUT ATTORNEY
STATE BAR NO.:
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:
CHILDREN'S NAMES:
CASE NUMBER:
FINANCIAL DECLARATION—JUVENILE DEPENDENCY
1.
Personal Information:
Name:
Social Security Number:
Other names used:
I.D. or Driver's License Number:
Date of Birth:
Age:
Mother
Father
Relationship to Child:
Other Responsible Person (specify):
Street or Mailing Address:
City:
State:
Zip:
Phone:
(___) ___-____
Alternate Phone:
(___) ___-____
Marital Status:
Married
Single
Domestic partner
Separated
Divorced
Widowed
Name of Spouse/Partner:
Number of dependents living with you:
Names and ages of dependents:
2.
I receive (check all that apply):
Medi-Cal
SNAP (food stamps)
SSI
SSP
County Relief/General Assistance
CalWORKS or Tribal TANF (Temporary Assistance to Needy Families)
IHSS (In-Home Supportive Services)
CAPI (Case Assistance Program for Aged, Blind, and Disabled)
3.
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 at
1
$1,264.59
3
$2,164.59
5
$3,064.59
home, add $450.00 for
each extra person.
2
$1,714.59
4
$2,614.59
6
$3,514.59
4.
I have been reunified with my child(ren) under a court order (attached).
5.
I am receiving court-ordered reunification services.
Page 1 of 3
Form Approved for Optional Use
Welfare and Institutions Code, §§ 903.1,
FINANCIAL DECLARATION—JUVENILE DEPENDENCY
Judicial Council of California
903.45(b), 903.47
JV-132 [Rev. March 2, 2018]
www.courts.ca.gov
CONFIDENTIAL
JV-132
ATTORNEY OR PARTY WITHOUT ATTORNEY
STATE BAR NO.:
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:
CHILDREN'S NAMES:
CASE NUMBER:
FINANCIAL DECLARATION—JUVENILE DEPENDENCY
1.
Personal Information:
Name:
Social Security Number:
Other names used:
I.D. or Driver's License Number:
Date of Birth:
Age:
Mother
Father
Relationship to Child:
Other Responsible Person (specify):
Street or Mailing Address:
City:
State:
Zip:
Phone:
(___) ___-____
Alternate Phone:
(___) ___-____
Marital Status:
Married
Single
Domestic partner
Separated
Divorced
Widowed
Name of Spouse/Partner:
Number of dependents living with you:
Names and ages of dependents:
2.
I receive (check all that apply):
Medi-Cal
SNAP (food stamps)
SSI
SSP
County Relief/General Assistance
CalWORKS or Tribal TANF (Temporary Assistance to Needy Families)
IHSS (In-Home Supportive Services)
CAPI (Case Assistance Program for Aged, Blind, and Disabled)
3.
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 at
1
$1,264.59
3
$2,164.59
5
$3,064.59
home, add $450.00 for
each extra person.
2
$1,714.59
4
$2,614.59
6
$3,514.59
4.
I have been reunified with my child(ren) under a court order (attached).
5.
I am receiving court-ordered reunification services.
Page 1 of 3
Form Approved for Optional Use
Welfare and Institutions Code, §§ 903.1,
FINANCIAL DECLARATION—JUVENILE DEPENDENCY
Judicial Council of California
903.45(b), 903.47
JV-132 [Rev. March 2, 2018]
www.courts.ca.gov
JV-132
CONFIDENTIAL
CHILDREN'S NAMES:
CASE NUMBER:
RESPONSIBLE PERSON'S NAME:
6.
Employment:
Your Employment
Your Spouse/Partner's Employment
Employer:
Employer:
Address:
Address:
City and Zip Code:
Phone:
City and Zip Code:
Phone:
(___) ___-____
(___) ___-____
Type of Job:
Type of Job:
Monthly salary:
Take home pay:
Monthly salary:
Take home pay:
How long
Working
How long
Working
employed:
now?
employed:
now?
If not now employed, who was your last employer?
If not now employed, who was this person's last employer?
(Name, Address, City, and Zip Code):
(Name, Address, City, and Zip Code):
Phone number of last employer:
(___) ___-____
Phone number of last employer:
(___) ___-____
7. Other Monthly Income and Assets:
Other Income
Assets: What Do You Own?
Unemployment ...............................................$
Cash ............................................................
$
Disability ........................................................ $
Real Property/Equity ....................................
$
Social Security ............................................... $
Cars and Other Vehicles ..............................
$
Workers' Compensation ................................ $
Life Insurance ..............................................
$
Child Support Payments ................................ $
Bank Accounts (list below).............................
$
Foster Care Payments ................................... $
Stocks and Bonds ........................................
$
Other Income ................................................. $
Business Interest .........................................
$
Total $
Other Assets ................................................
$
Total $
Name and branch of bank:
Account numbers:
FINANCIAL DECLARATION—JUVENILE DEPENDENCY
JV-132 [Rev. March 2, 2018]
Page 2 of 3
JV-132
CONFIDENTIAL
CHILDREN'S NAMES:
CASE NUMBER:
RESPONSIBLE PERSON'S NAME:
8. Expenses:
Monthly Household Expenses
Reunification Plan: Monthly Cost of Required Services
Rent or Mortgage Payment ...........................
$
Parenting Classes .........................................
$
Car Payment .................................................
$
Substance Abuse Treatment ........................
$
$
Gas and Car Insurance .................................
$
Therapy/Counseling ......................................
Medical Care/Medications .............................
$
Public Transportation ....................................
$
Utilities (Gas, Electric, Phone, Water, etc.)....
$
Domestic Violence Counseling .....................
$
Food ..............................................................
$
Batterers' Intervention ...................................
$
Clothing and Laundry ....................................
$
Victim Support ..............................................
$
Child Care .....................................................
$
Regional Center Programs ...........................
$
Child Support Payments ...............................
$
Transportation ...............................................
$
Medical Payments .........................................
$
In-Home Services .........................................
$
Other Necessary Monthly Expenses .............
Other .............................................................
$
Total $
Total $
9. Loan/Expense Payments (other than mortgage or car loan):
Name of lender and type of loan/expense
Monthly payment
Balance owed
$
$
$
$
$
$
$
$
I declare under penalty of perjury under the laws of the State of California that the above information is true and correct.
Date:
(TYPE OR PRINT NAME)
(SIGNATURE OF DECLARANT)
FOR FINANCIAL EVALUATION OFFICER USE ONLY
TOTAL INCOME
$
COST OF LEGAL SERVICES
$
TOTAL EXPENSES
$
MONTHLY PAYMENT
$
NET DISPOSABLE INCOME
$
TOTAL COST ASSESSED
$
The above-named responsible person is presumed unable to pay reimbursement for the cost of legal services in this proceeding and
is eligible for a waiver of liability because
he or she receives qualifying public benefits
his or her household income falls below 125% of the current federal poverty guidelines
he or she has been reunified with the child(ren) under a court order and payment of reimbursement would harm his or her
ability to support the child(ren).
Date:
(SIGNATURE OF FINANCIAL EVALUATION OFFICER)
(TYPE OR PRINT NAME)
FINANCIAL DECLARATION—JUVENILE DEPENDENCY
JV-132 [Rev. March 2, 2018]
Page 3 of 3
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