Domestic Partnership - Superior Court, Riverside - State of California

PETITIONER/PLAINTIFF:RESPONDENT/DEFENDANT:OTHER PARENT/CLAIMANT:CASE NUMBER:FL-15012.The following people live with me:NameAgeHow the person isrelated to me? (ex: son)That person's grossmonthly incomePays some of thehousehold expenses?a.Yes Nob.Yes Noc.Yes Nod.Yes Noe. Yes No13.14.15.Average monthly expensesEstimated expenses Actual expenses Proposed needsa. Home:h. Laundry and cleaning . . . . . . . . . . . . . . . . . $(1) Rent or mortgage. . . $i. Clothes . . . . . . . . . . . . . . . . . . . . . . . . . . . . $If mortgage:j. Education . . . . . . . . . . . . . . . . . . . . . . . . . . $(a) average principal: $k. Entertainment, gifts, and vacation. . . . . . . . $(b) average interest: $l. Auto expenses and transportation(2) Real property taxes . . . . . . . . . . . . . . $(insurance, gas, repairs, bus, etc.) . . . . . . . $(3) Homeowner's or renter's insurancem. Insurance (life, accident, etc.; do not(if not included above) . . . . . . . . . . . . $include auto, home, or health insurance). . . $n. Savings and investments. . . . . . . . . . . . . . .(4)$Maintenance and repair . . . . . . . . . . . $o. Charitable contributions. . . . . . . . . . . . . . . . $b. Health-care costs not paid by insurance. . . $p. Monthly payments listed in item 14c.d.Child care . . . . . . . .. . . . . . . . . . . . . . . . . . $Groceries and household supplies. . . . . . . $q.(itemize below in 14 and insert total here). .Other (specify): . . . . . . . . . . . . . . . . . . . . . .$$e.f.Eating out. . . . . . . . . . . . . . . . . . . . . . . . . . $Utilities (gas, electric, water, trash) . . . . . . $r. TOTAL EXPENSES (a–q) (do not add inthe amounts in a(1)(a) and (b))$g. Telephone, cell phone, and e-mail . . . . . . . $s. Amount of expenses paid by others $Installment payments and debts not listed abovePaid toForAmountAttorney fees (This is required if either party is requesting attorney fees.):a. To date, I have paid my attorney this amount for fees and costs (specify): $b. The source of this money was (specify):c. I still owe the following fees and costs to my attorney (specify total owed): $d. My attorney's hourly rate is (specify): $$$$$Balance$$$$$ $$ $Date of last paymentI confirm this fee arrangement.Date:FL-150 [Rev. January 1, 2007](TYPE OR PRINT NAME OF ATTORNEY)INCOME AND EXPENSE DECLARATION(SIGNATURE OF ATTORNEY)Page 3 of 4