City, State, Zip 

 
Name 

 
Address 

 
Phone 

 
Email 

 

This is a private record. 

 
 
 
 
 
 
 
Check your email. You will receive information and 
documents at this email address. 
 

I am   [  ]  Petitioner 

[  ]  Petitioner’s Attorney 
[  ]  Petitioner’s Licensed Paralegal Practitioner 
[  ]  Respondent’s Licensed Paralegal Practitioner   

[  ]  Respondent 
[  ]  Respondent’s Attorney   

(Utah Bar #:__________) 

(Utah Bar #:__________) 

In the District Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

In the Matter of (select one) 
 

[  ]  the Marriage of (for a divorce with or without 
children, annulment, separate maintenance, or 
temporary separation case) 

[  ]  the Children of (to establish custody, parent-

time or child support) 

[  ]  the Parentage of the Children of (for a 

paternity case) 

____________________________________ 
(name of Petitioner) 

and  

____________________________________ 
(name of Respondent) 
____________________________________________ 
Other parties (if any) 

Income Verification 
(Utah Code 78B-12-203(5)) 

[  ] and Statement of Compliance 
with Child Support Guidelines 
(Utah Code 78B-12-201 et seq.) 

_______________________________ 
Case Number 

_______________________________ 
Judge 

_______________________________ 
Commissioner 

Proof of income 
(You are required to provide the court proof of income for both parties.) 

1. 

Year-to-date pay stubs or employer statements for petitioner:  

[  ]  are attached and the party's social security number has been blacked out. 

1052FAJ Approved July 18, 2019 / 
Revised May 1, 2021 

Income Verification and Statement of Compliance 
with Child Support Guidelines 

Page 1 of 4 

 

[  ]  have already been submitted. 

[  ]  are not attached because:  

 

2. 

Year-to-date pay stubs or employer statements for respondent: 

[  ]  are attached and the party's social security number has been blacked out. 

[  ]  have already been submitted. 

[  ]  are not attached because:  

3. 

The most recent tax returns for petitioner:   

[  ]  are attached and the party's social security number has been blacked out. 

[  ]  have already been submitted. 

[  ]  are not attached because:  

4. 

The most recent tax returns for respondent:  

[  ]  are attached and the party's social security number has been blacked out. 

[  ]  have already been submitted. 

[  ]  are not attached because:  

Child support worksheets (If applicable.) 

5. 

The following worksheet, which is filed or attached, was used to determine the 
child support amount: 

[  ]  sole physical custody worksheet 

[  ]  joint physical custody worksheet 

1052FAJ Approved July 18, 2019 / 
Revised May 1, 2021 

Income Verification and Statement of Compliance 
with Child Support Guidelines 

Page 2 of 4 

 

   

   

   

   

 

[  ]  split custody worksheet 

Compliance with child support guidelines (If applicable.) (Utah Code 78B-12-202) 

6. 

[  ]  The child support amount is based on the Uniform Child Support Guidelines  

[  ]  The child amount is not based on the Uniform Child Support Guidelines. 

laintiff/Petitioner or Defendant/Respondent  

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). 

ttorney or Licensed Paralegal Practitioner of record (if applicable) 

Signature ► 

Printed Name 

Signature ► 

Printed Name 

 

 

 

 

1052FAJ Approved July 18, 2019 / 
Revised May 1, 2021 

Income Verification and Statement of Compliance 
with Child Support Guidelines 

Page 3 of 4 

  P

    A

 
Date 

 
Date 

 

 

 

 

 

I certify that I filed with the court and am serving a copy of this Income Verification and Statement of 
Compliance with Child Support Guidelines on the following people. 

Certificate of Service 

Person’s Name 

Service Method 

Service Address 

Service 
Date 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email  
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email 
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email  
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

 

 

 

 
Date 

Signature ► 

Printed Name 

 

 

1052FAJ Approved July 18, 2019 / 
Revised May 1, 2021 

Income Verification and Statement of Compliance 
with Child Support Guidelines 

Page 4 of 4