COUNTY OF SANTA BARBARA PROBATION DEPARTMENT FINANCIAL STATEMENT v.2.10.17

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Parent completing form:

Name of Minor:

Minor Date of Birth:

Other parent of minor:

1. a. Address:	City:	State:	Zip code:	b. Home phone:	c. Cell phone:	d. Email address:
2. a.  My only source of income is Calworks, SSI or GA/GR
b   I have applied for CalWorks, SSI or GA/GR

3. I am the parent of the following number of natural or adopted children from this relationship................................................
4. a. The children from this relationship are with me this amount of time...............................................................................
b. The children from this relationship are with the other parent this amount of time..............................................................
c.  Our arrangement for custody and visitation is (specify):
5. My tax filing status is:SingleMarried file jointlyHead of householdMarried filing separately
6. My current gross income (before taxes) per month is .....................................................................................................	$
This income comes from the following:
Salary/wages: Amount before taxes per month  ......................................................................................................	$
Retirement: Amount before taxes per month  .........................................................................................................	$
Unemployment compensation: Amount per month  .................................................................................................	$
Workers’ compensation: Amount per month  ..........................................................................................................	$
Social Security:  SSI Other amount per month     ....................................................	$
Aid   CalWorks  GR/GA  ...............................................................................................................................	$
Disability: Amount per month  ...............................................................................................................................	$
Interest income (from bank accounts or other): Amount per month  ..........................................................................	$
I have no other sources of income