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Here is the text we could read:

 

 

In the Juvenile Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

State of Utah, in the interest of 

_____________________________________ 
Last name, first name 

_____________________________________ 
Date of birth 

 

 minor under 18 years of age, and   
[  ] represented    [  ] not represented. 

Declaration of Income and Expenses 
in Support of Petition for 
Emancipation 

_______________________________ 
Case Number 

_______________________________ 
Judge 

I am submitting this declaration in support of my Petition for Emancipation.  

Income 
[  ]  I have the following job(s). My employer’s 
name and address is: 

Monthly pay 
before deductions: 
$ _____________ 

Monthly pay after 
deductions: 
$ _____________ 

If you do not have a job, write “None” in this space) 

1502JUF Approved August 9, 2021 

Declaration of Income and Expenses in Support of 
Petition for Emancipation 

Page 1 of 4 

  A

      (

 

 
Name 

 
Address 

 
City, State, Zip 

 
Phone 

 
Email 

 

I am   [  ]  Plaintiff/Petitioner 

[  ]  Plaintiff/Petitioner’s Attorney   

 
 
 
 
 
 
 
 
 

 

Monthly income, 
non-wage: 
$ _____________ 

Monthly income, 
from government 
programs: 
$ _____________ 

     

     

  $

  $

Monthly pay, 
before deductions, 
of others in 
household: 

Monthly pay after 
deductions of 
others in 
household: 

  $

  $

 _____________ 

 _____________ 

 _____________ 

 _____________ 

[  ]  I share a household with others, some of 
whom have jobs and share the cost of 
household expenses. The names of these 
household members are: 
Name:  
____________________________________ 
Name: 
____________________________________ 

ssets 
[  ]  I have this much money in cash, in the bank, in stocks or 
bonds, and in other available sources: 

$ _____________ 

[  ]  Other people or organizations owe me this much money: 

$ _____________ 

[  ]  I own or am buying a home, land, other real property, vehicles, other personal 
property, or business interests as listed below: 

Property (home, land, vehicles, etc.) and 
location 

Balance Owed 

Value 

Home  
 

Land and other real property 
 

Cars, trucks, or other vehicles 
 

Other personal property 
 

$ _____________  $ _____________ 

$ _____________  $ _____________ 

$ _____________  $ _____________ 

$ _____________  $ _____________ 

1502JUF Approved August 9, 2021 

Declaration of Income and Expenses in Support of 
Petition for Emancipation 

Page 2 of 4 

  A

 

[  ]  I have income from sources other than 
employment (include such sources as rental 
income, money, or other support). 

Source of Income 

[  ]  I receive this much per month from 
government programs (Include such sources as 
social security benefits, workers’ compensation, 
housing, food, and other living allowances). 

Source of Income 

Business interests 
 

$ _____________  $ _____________ 

ebt 
[  ]  I owe the following debts (name): 

 

 

 

Amount 

$ _____________ 

$ _____________ 

$ _____________ 

xpenses 
[  ]  In an average month, I spend money for the following items 

Amount 

 

Amount 

$ _____________  Water 

$ _____________ 

$ _____________ 

Telephone 

$ _____________ 

$ _____________ 

$ _____________ 

Uninsured medical 
expenses 

Transportation 

$ _____________ 

Health insurance 

$ _____________ 

Electricity 

$ _____________ 

Child support 

$ _____________ 

$ _____________ 

Education expense 

$ _____________ 

$ _____________ 

$ _____________ 

Other (list) 
 

Food 

Clothing 

Housing 

Gas 

Other (list) 
 

I declare under criminal penalty under the law of Utah that everything stated in this document is true. 

Signed at ______________________________________________________ (city, and state or country). 

 
Date 

Signature ► 

Printed Name 

 

 

1502JUF Approved August 9, 2021 

Declaration of Income and Expenses in Support of 
Petition for Emancipation 

Page 3 of 4 

  D

 

  E

 

  

 

 

 

 

 

 

 

 

 

I certify that I filed with the court and am serving a copy of this Declaration of Income and Expenses in 
Support of Petition for Emancipation on the following people. 

Certificate of Service 

Person’s Name 

Service Method 

Service Address 

Service 
Date 

 

 

 

 

 

 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email  
[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email  
[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email  
[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email  
[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email  
[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email  

Signature ► 

Printed Name 

 

 

(Attorney General) 

(Guardian ad Litem) 

 

 

Parent 

Parent 

(Other) 

(Other) 

 
Date 

 

1502JUF Approved August 9, 2021 

Declaration of Income and Expenses in Support of 
Petition for Emancipation 

Page 4 of 4

Declaration of Income and Expenses in Support of Petition for Emancipation

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Utah state courts. To learn more about the project, check out our about page.

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): 4
Fields(s): 99
Average fields per page: 24
Reading Level: Grade 11
LIST Grouping(s): GO-00-00-00-00.

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

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.

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

Declaration of Income and Expenses in Support of Petition for Emancipation

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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