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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 

 

Declaration of Financial Status 
(Juvenile) 
(Utah Code 78B-22-202 and 78B-22-203) 

_______________________________ 
Case Number 

_______________________________ 
Judge 

1.  I am (Choose one.): 

[  ]  The parent or legal guardian of a minor in juvenile court, and  

[  ]  I am requesting a court-appointed attorney for myself in a child welfare case 

or a case where my parental rights could be terminated.  

[  ]  I am providing a declaration of financial status as requested by the court.  

[  ]  An adult being charged with a criminal offense in the juvenile court.  

I understand the court may require me to reimburse fees for a court-appointed 
attorney. 

2.  I say the following (Choose all that apply.): 

[  ]  I can’t afford an attorney.   
[  ]  An attorney has been appointed for my child and I am required to fill this out by 

court order 

3.  The following people depend on me for support. 

Number of adults (including yourself) 

 

 

Number of children under 18 

 

4.  [  ]  I am employed full-time. 

[  ]  I am employed part-time. 

[  ]  I am unemployed.  

Source of income 

Source of income 

Monthly 
amount 

Monthly 
amount 

$ 

$ 

Public / government 
assistance 

Other (Describe) 
 

$ 

$ 

Total monthly income  $ 

5.  Monthly Income  

Work   

Other (Describe) 

   

1200JUF Approved September 9, 2019 
/ Revised January 4, 2022 
 

Declaration of Financial Status (Juvenile) 

Page 1 of 2 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

 

(Include amounts you pay for yourself and any spouse, children or other dependents in your 
household.) 

Monthly expense 

Rent or mortgage 

Current 
Amount 

Monthly expense 

Child support and alimony 

Current 
Amount 

Education (children or self) 

Child care 

.  Monthly Expenses   

  6

Transportation (car payments, fuel, 
insurance, public transit, parking) 
Credit card, loan, garnishments, 
and other debt payments 
Phone, internet and paid television 
(cable, satellite, streaming) 
Other (describe) 
 

$ 

$ 

$ 

$ 

$ 

$ 

Food, clothing and 
household supplies 
Health care insurance and 
expenses 
Utilities  (electricity, gas, 
water, sewer, garbage) 
Other (describe) 
 

Total monthly expenses  $ 

7.   Financial Assets  (Add additional sheets if needed.) 

Asset 

Value 

Balance Owing 

Other vehicles (OHV, boat, motorcycle, snowmobile, RV) 

[  ]  I would like the judge to consider these other circumstances regarding my 

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

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

Signature ► 

Printed Name 

 

 

1200JUF Approved September 9, 2019 
/ Revised January 4, 2022 
 

Declaration of Financial Status (Juvenile) 

Page 2 of 2 

Bank accounts 

Personal property  

Other (describe) 
 

8.  Other 

finances: 

   

Home  

Land 

Cars 

  I

 

 
Date

Declaration of Financial Status (Juvenile)

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): 2
Fields(s): 63
Average fields per page: 31
Reading Level: Grade 9
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.

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page_field__2 was page_0_field_4 (0.31 conf)
page_field__3 was page_0_field_5 (0.31 conf)
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financial_status_requested was i_am_providing_a_declaration_of_financial_status_as_requested_by_the_court (0.47 conf)
parent_legal_guardian_minor was the_parent_or_legal_guardian_of_a_minor_in_juvenile_court__and (0.43 conf)
charged_criminal_court was an_adult_being_charged_with_a_criminal_offense_in_the_juvenile_court (0.42 conf)
afford_attorney was i_can_t_afford_an_attorney (0.45 conf)
attorney_required_fill was an_attorney_has_been_appointed_for_my_child_and_i_am_required_to_fill_this_out_by (0.48 conf)
employed_full_time was 4_i_am_employed_full_time (0.34 conf)
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city_state_country was city__and_state_or_country (0.47 conf)
users1_signature was signature (1.00 conf)
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page_field__31 was page_1_field_4 (0.36 conf)
page_field__32 was page_1_field_5 (0.36 conf)
declare_criminal_stated was i_declare_under_criminal_penalty_under_the_law_of_utah_that_everything_stated_in_this_document_is_true (0.52 conf)
signed was signed_at (0.36 conf)
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signature_date was date (1.00 conf)
page__2 was page_2_of_2 (0.42 conf)
page_field__34 was page_1_field_11 (0.36 conf)
would_consider_regarding was i_would_like_the_judge_to_consider_these_other_circumstances_regarding_my (0.35 conf)

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

Declaration of Financial Status (Juvenile)

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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