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Here is the text we could read:

Complete this only if you believe that you may qualify to have your fees reduced or waived  

   

CO-PARENTING MEDIATION 
INCOME SURVEY 

HOUSEHOLD INFORMATION: List yourself and all people living with you regardless 
of age or relationship to you.  If any person is over 18 years of age, list their gross monthly 
income. 

 

ames  

 

 

Birth Date  Relationship to You  Monthly Salary 

______________________  ___________  SELF____________  _________________ 

______________________  ___________  _________________  _________________ 

______________________  ___________  _________________  _________________ 

______________________  ___________  _________________  _________________ 

______________________  ___________  _________________  _________________ 

______________________  ___________  _________________  _________________ 

INANCIAL INFORMATION- Are You Currently Employed? (Please Circle One)  YES       NO 

 

 
Employment: (If not currently employed, list past employer).   

   

 

 

 

 

 

 

Employer: 

 

__________________________________________ 

 

Address: 

__________________________________________ 

 

 
Phone #: 
 
 
 
Supervisor: 
 
 
 
Type of Work:  

__________________________________________ 

__________________________________________ 

__________________________________________ 

Hourly Wage:  

$__________  Number of hours per week: ________ 

Gross Monthly: 

$__________  Dates of Employment _______to________ 

Please complete entire form (turn over) 

 

  N

  _

  _

  _

  _

  _

  _

  F

 

   

   

   

 
 
 
 

   

   

 

GOVERNMENT BENEFITS 

(√) All that apply 

OAFDC 

 

$____________________ 

OTHER INCOME  (√) All that apply 

O Social Security 

 

$___________________ 

O Veteran’s Pension   

$___________________ 

O Retirement/Pension 

$___________________ 

O Rental Income 

 

$___________________ 

O Unemployment Comp. 

$___________________ 

O Disability Benefits $___________________ 

$___________________ 
    (Paid) 

 

___________________ 
  (Received) 

  $

 Child Support 

$___________________ 
  (Paid) 

 Other 

$___________________ 

 

 

 
 

 

O Alimony  

 

  

 

 

 

 

  O

 

 

  O

 
 

TATEMENT OF VERIFICATION 

 

 

 

 

 

 

 

 

 

 
 

    S

 

This must be completed and signed before the mediation session to have the fee reduced 
or waived.  Incomplete or late surveys will not be accepted. 

 verify under the penalties of perjury that the figures given above are true and correct, 
and that if any of these figures change, I will inform the Co-Parenting Mediation 
Program immediately. 

________________________________________  _____________________________ 
 
Signature 

Date 

 

 

 

 

 I

  _

Co-Parenting Mediation Income Survey

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): 3
Fields(s): 49
Average fields per page: 16
Reading Level: Grade 11
LIST Grouping(s): GO-00-00-00-00, DI-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.

may_qualify_fees_reduced was complete_this_only_if_you_believe_that_you_may_qualify_to_have_your_fees_reduced_or_waived (0.62 conf)
date_monthly_salary was birth_date__relationship_to_you__monthly_salary (0.43 conf)
page_field__1 was page_0_field_2 (0.31 conf)
names was names (0.39 conf)
page_field__2 was page_0_field_4 (0.31 conf)
self was self (0.34 conf)
page_field__3 was page_0_field_6 (0.31 conf)
page_field__4 was page_0_field_7 (0.31 conf)
page_field__5 was page_0_field_8 (0.31 conf)
page_field__6 was page_0_field_9 (0.31 conf)
page_field__7 was page_0_field_10 (0.31 conf)
page_field__8 was page_0_field_11 (0.31 conf)
page_field__9 was page_0_field_12 (0.31 conf)
page_field__10 was page_0_field_13 (0.31 conf)
page_field__11 was page_0_field_14 (0.31 conf)
page_field__12 was page_0_field_15 (0.31 conf)
financial_one_yes was financial_information__are_you_currently_employed_please_circle_one_yes_no (0.43 conf)
page_field__13 was page_0_field_17 (0.31 conf)
page_field__14 was page_0_field_18 (0.31 conf)
page_field__15 was page_0_field_19 (0.31 conf)
page_field__16 was page_0_field_20 (0.31 conf)
employment_currently_employer was employment_if_not_currently_employed__list_past_employer (0.37 conf)
page_field__17 was page_0_field_22 (0.31 conf)
page_field__18 was page_0_field_23 (0.31 conf)
users1_address_line_one was address (1.00 conf)
page_field__19 was page_0_field_25 (0.31 conf)
supervisor was supervisor (0.38 conf)
page_field__20 was page_0_field_27 (0.31 conf)
af_f was AFF028 (0.51 conf)
to was to (0.43 conf)
page_field__21 was page_0_field_30 (0.31 conf)
page_field__22 was page_0_field_31 (0.31 conf)
page_field__23 was page_0_field_32 (0.31 conf)
page_field__24 was page_0_field_33 (0.31 conf)
page_field__25 was page_1_field_0 (0.31 conf)
page_field__26 was page_1_field_1 (0.36 conf)
page_field__27 was page_1_field_2 (0.36 conf)
page_field__28 was page_1_field_3 (0.36 conf)
page_field__29 was page_1_field_4 (0.36 conf)
page_field__30 was page_1_field_5 (0.36 conf)
page_field__31 was page_1_field_6 (0.36 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)
page_field__35 was page_1_field_10 (0.36 conf)
veteran_pension was o_veteran_s_pension (0.35 conf)
retirement_pension was o_retirement_pension (0.43 conf)
signature_date was date (1.00 conf)
users1_signature was signature (1.00 conf)

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

Co-Parenting Mediation Income Survey

About This Form:

Identified Data Fields:

Create an Interactive Version of this Form:

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