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Here is the text we could read:

Solamente complete esto si cree calificar para obtener una tarifa reducida o retirada condonada. 
 
PROGRAMA DE MEDIACIÓN FAMILIAR 
FORMULARIO DE VERIFICACION DE INGRESOS 

INFORMACIÓN DE FAMILIA:   Por favor haga una lista de todas las personas que viven en 
la misma casa con usted (ya sean sus familiares o no).  También haga favor de escribir el 
ingreso mensual de todas las personas mayores de 18 aňos de edad que viven en su casa. 

 

ombres        Fecha de Nacimiento   Que relacion tiene con usted    Ingreso Mensual 

___________________    _____________    ___Nombre suyo___     ________________ 

___________________    _____________    _________________     ________________ 

___________________    _____________    _________________     ________________ 

___________________    _____________    _________________     ________________ 

___________________    _____________    _________________     ________________ 

___________________    _____________    _________________     ________________ 

___________________    _____________    _________________     ________________ 

  
INFORMACIÓN FINANCIERA   

A. 

Empleo — si no esta empleado, por favor ponga información de su ứltimo 
empleo. 

Empleador 

 

____________________________________________ 

Dirección 

____________________________________________ 

Numero Telefónico  ______________________________________ 

Supervisor  ____________________________________________ 

Típo de Empleo 

____________________________________________ 

Pago Por Hora 

$                    Numero de horas por semana_________ 

Ingreso Mensual 

$                    Fecha en que comenzó a trabajar_______ 

I.  

  N

II. 
 

 

 

   

                    Social Security 

$___________                                

                   Pensión de Veterano  

$___________                                  

                   Pensión de Jubilación 

$___________                                   

                  

Ingreso de rentas 

$___________                                   

                   Compensación de desempleo 

$___________                                   

                   Beneficios de deshabilidades 

$___________                     

                    Alimony 

 

$___________ 

________   Child Support  

$___________ 

(Sosten económico para usted  
y para sus hijos) 
 

 

 

                                    

                    Otro (éspecifique) 

 

$___________                                    

 

 

 

 

 

 

 

 

 

 

 

  _

 

 

 

 

 

 

 

 

B. 

Beneficios del Gobierno — cuanto recibe de cada uno de los siguientes 
beneficios 

                    AFDC  

 

$__________                                    

 

 

  

C. 

Other Income — () Marque todos los que aplíquen  

III.  VERIFICACIÓN DE INGRESOS  
 

éste formulario se debe de completar y firmar antes de la sesion inicial de mediación si usted 
desea que consideremos reducirle los honorarios. Es necesario completar todo el formulario 
o no lo aceptaremos. 

Yo verifíco bajo penalidades de perjurio que los numeros que he llenado en éste 
formulario son verídicos y correctos y que si estos  numeros cambian durante éste 
proceso, notificaré al programa de mediación familiar inmediatamente.  

______________________________  
Firma   

 

 

 

 

___________________________ 
 

Fecha

Programa de Mediacion Familiar Fromulario de Verificacion de Ingresos (Co-Parenting Mediation Income Survey)

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Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from legacy.utcourts.gov (2023-03)
Page(s): 2
Fields(s): 61
Average fields per page: 30
Reading Level: Grade 13
LIST Grouping(s): GO-00-00-00-00.

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Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

esto_obtener_tarifa was solamente_complete_esto_si_cree_calificar_para_obtener_una_tarifa_reducida_o_retirada_condonada (0.63 conf)
nombres_que_relacion_usted was nombres_fecha_de_nacimiento_que_relacion_tiene_con_usted_ingreso_mensual (0.56 conf)
nombre_suyo was nombre_suyo (0.53 conf)
page_field__1 was page_0_field_3 (0.31 conf)
page_field__2 was page_0_field_4 (0.31 conf)
page_field__3 was page_0_field_5 (0.31 conf)
page_field__4 was page_0_field_6 (0.31 conf)
page_field__5 was page_0_field_7 (0.31 conf)
page_field__6 was page_0_field_8 (0.31 conf)
page_field__7 was page_0_field_9 (0.31 conf)
page_field__8 was page_0_field_10 (0.31 conf)
page_field__9 was page_0_field_11 (0.31 conf)
page_field__10 was page_0_field_12 (0.31 conf)
page_field__11 was page_0_field_13 (0.31 conf)
page_field__12 was page_0_field_14 (0.31 conf)
page_field__13 was page_0_field_15 (0.31 conf)
page_field__14 was page_0_field_16 (0.31 conf)
page_field__15 was page_0_field_17 (0.31 conf)
page_field__16 was page_0_field_18 (0.31 conf)
page_field__17 was page_0_field_19 (0.31 conf)
page_field__18 was page_0_field_20 (0.31 conf)
page_field__19 was page_0_field_21 (0.31 conf)
page_field__20 was page_0_field_22 (0.31 conf)
page_field__21 was page_0_field_23 (0.31 conf)
page_field__22 was page_0_field_24 (0.31 conf)
page_field__23 was page_0_field_25 (0.31 conf)
page_field__24 was page_0_field_26 (0.31 conf)
informaci_n_financiera was información_financiera (0.44 conf)
page_field__25 was page_0_field_28 (0.31 conf)
ii was ii (0.41 conf)
si_esta_empleado_por_su was empleo_si_no_esta_empleado__por_favor_ponga_información_de_su_ứltimo (0.54 conf)
direcci_n was dirección (0.47 conf)
numero_telef_nico was numero_telefónico (0.42 conf)
numero_de_horas_por_semana was numero_de_horas_por_semana (0.52 conf)
page_field__26 was page_0_field_34 (0.31 conf)
page_field__27 was page_0_field_35 (0.31 conf)
fecha_en_que_comenz_trabajar was fecha_en_que_comenzó_a_trabajar (0.47 conf)
page_field__28 was page_0_field_37 (0.37 conf)
page_field__29 was page_0_field_38 (0.37 conf)
afdc was afdc (0.35 conf)
af_f was AFF040 (0.51 conf)
social_security was social_security (0.40 conf)
page_field__30 was page_1_field_3 (0.36 conf)
pensi_n_de_veterano was pensión_de_veterano (0.44 conf)
page_field__31 was page_1_field_5 (0.36 conf)
pensi_n_de_jubilaci was pensión_de_jubilación (0.47 conf)
page_field__32 was page_1_field_7 (0.36 conf)
page_field__33 was page_1_field_8 (0.36 conf)
page_field__34 was page_1_field_9 (0.36 conf)
compensaci_n_de_desempleo was compensación_de_desempleo (0.56 conf)
page_field__35 was page_1_field_11 (0.36 conf)
beneficios_de_deshabilidades was beneficios_de_deshabilidades (0.49 conf)
page_field__36 was page_1_field_13 (0.36 conf)
alimony was alimony (0.38 conf)
page_field__37 was page_1_field_15 (0.36 conf)
page_field__38 was page_1_field_16 (0.36 conf)
page_field__39 was page_1_field_17 (0.36 conf)
otro_specifique was otro__éspecifique (0.43 conf)
page_field__40 was page_1_field_19 (0.36 conf)
fecha was fecha (0.48 conf)
firma was firma (0.55 conf)

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Programa de Mediacion Familiar Fromulario de Verificacion de Ingresos (Co-Parenting Mediation Income Survey)

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Identified Data Fields:

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02