Financial Declaration-Subsequent Financial Declaration {JV-2020}

(CONFIDENTIAL) ATTACHMENT JV-2020 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number and Address): FOR COURT USE ONLY TELEPHONE NUMBER: EMAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NUMBER (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA COURT ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: CHILDREN'S NAMES: 191 North First Street San José, CA 95113 Juvenile Dependency Time: Dept. THIS SECTION FOR COURT USE ONLY SUBSEQUENT FINANCIAL DECLARATION I am Requesting a Hearing for Reconsideration of my Order to Repay Attorney Fees filed on (date): My Request is Based on: Change of Financial Circumstances Financial Inability to Comply with Reunification Plan Requirements Hearing Date Reconsideration Hearing Date: Time: Dept. Hearing Date FINANCIAL DECLARATION Financial Evaluation Hearing Date: CASE NUMBER: RELATED CASES: 1. Personal Information: Name: Other Names Used: Address: Check here if you are In custody. Detention Center: Release Date: City: Zip Code: Social Security Number: I.D. or Driver's License: Date of Birth: Age: Phone: Alternate Phone: 2. I receive (check all that apply): Medi-Cal SNAP SSI SSP County/Relief/General Assistance IHSS (In-Home Supportive Services) CalWORKS or Tribal TANF (Tribal Temporary Assistance to Needy Families) CAPI (Case Assistance Program for Aged, Blind and Disabled) 3. My gross monthly income (before deductions for taxes) is less than the amount listed below: If you checked box 3, circle the Family Income section that applies to your case. Family Size 1 2 Family Income $1, $1, Family Size 3 4 Family Income $, $2, Family Size 5 6 Family Income $2, $3, If more than 6 people in family, add $ for each extra person. If you checked any boxes in section 2 or 3 above, skip sections 4 through 8. Go to section 9, read and fill in the section and sign the form. American LegalNet, Inc. www.FormsWorkFlow.com JV-2020 0 FINANCIAL DECLARATION / SUBSEQUENT FINANCIAL DECLARATION Page 1 of 4 (CONFIDENTIAL) ATTACHMENT JV-2020 CHILDREN'S NAMES: RESPONSIBLE PARTY'S NAME: CASE NUMBER: RELATED NUMBERS: 4. Family: a. Marital Status: b. c. d. Single Married Divorced Separated Widowed Domestic Partner Name of Spouse/Partner: Number of Dependent Children Living with You Who are Under the Age of 18: Dependents' Names and Ages: 5. Employment: Your Employment Spouse/Partner Employment If you checked "Married" or "Domestic Partner" in 4a, above, fill out this section. Employer: Address: Phone: Monthly Salary: Take Home Pay: City and Zip Code: How Long Employed? Working Now? Phone: Monthly Salary: Take Home Pay: Employer: Address: City and Zip Code: How Long Employed? Working Now? If not now employed, who was your last employer? (Name, Address and Zip Code) If not now employed, who was your last employer? (Name, Address and Zip Code) Phone number of last employer: Phone number of last employer: 6. Income and Assets: Other Income What do you own? Cash ...................................................$ Real Property/Equity ................................$ Cars and Other Vehicles ..........................$ Life Insurance...........................................$ Bank Accounts (list below) .......................$ Stocks and Bonds ....................................$ Business Interest......................................$ Unemployment and Disability .................. $ Social Security/ /SSD............................... $ General Relief.......................................... $ Worker's Compensation........................... $ Child Support Payments .......................... $ Foster Care.............................................. $ Other Income ........................................... $ Total $ 0 Other Assets.............................................$ Total $ 0 Name and Branch of Bank: Account Numbers: American LegalNet, Inc. www.FormsWorkFlow.com JV-2020 FINANCIAL DECLARATION / SUBSEQUENT FINANCIAL DECLARATION Page 2 of 4 (CONFIDENTIAL) ATTACHMENT JV-2020 CHILDREN'S NAMES: RESPONSIBLE PARTY'S NAME: CASE NUMBER: RELATED NUMBERS: 7. Expenses List your monthly expenses Monthly cost of services required by your reunification plan (If you do not know the cost, please indicate "UK" ) Parenting Classes ...... ......................... $ Substance Abuse Trmt .......................... $ Therapy/Counseling ......................... $_______________ Medical Care/Medications ........................$ Domestic Violence Counseling.................$ Batterers' Intervention ............................ $ Victim Support ..........................................$ Regional Center Programs .......................$ Transportation ........................................ $ In-Home Services.....................................$ Rent or Mortgage Payment...................... $ Car Payment............................................ $ Gas and Car Insurance............................ $ Public Transportation ............................... $ Utilities (Gas, Electric, Phone, Water)...... $ Food....................................................... $ Clothing and Laundry............................... $ Child Care................................................ $ Child Support Payments ........................ $ Medical Expenses.................................... $ Other Necessary Monthly Expenses........ $ Total $ 0 Other ........................................................$ Other ........................................................$ Total $ 0 8. Loan/Expense Payments Name of lender and type of loan/expense $ $ $ Monthly Payment $ $ $ Balance Owed American LegalNet, Inc. www.FormsWorkFlow.com JV-2020 FINANCIAL DECLARATION / SUBSEQUENT FINANCIAL DECLARATION Page 3 of 4 (CONFIDENTIAL) ATTACHMENT JV-2020 CHILDREN'S NAMES: RESPONSIBLE PARTY'S NAME: CASE NUMBER: RELATED NUMBERS: 9. I, , understand that a hearing will be set to determine my ability to pay the costs for legal services. If I do not appear at the hearing and do not pay in full the assessed costs for legal services, the court may enter a judgment against me without further notice or order. I understand that I have a right to a separate evidentiary hearing to determine my ability to pay the assessed fees, in the event that I dispute the judicial officer's order for repayment. I further understand that I am entitled to the following at that evidentiary hearing: The opportunity to be heard in person; The opportunity to present witnesses and written evidence; The opportunity to co