In the Juvenile Court of Utah 

Seventh Judicial District Grand County 

Court Address: 125 E Center St., Moab, UT 84532 

State of Utah, in the interest of 

_____________________________________ 
Last name, first name 

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

_______________________________ 
Case Number 

_____________________________________ 
Date of birth 

 

_______________________________ 
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. 

[  ]  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.   

[  ]  My child has been appointed an attorney and I’m required to fill this out by 

court order. 

3. 

Dependents (Count spouse and children under 18 in your household.) 

The following people depend on me for support. 

            Relationship      

      Age 

             Relationship       

     Age 

               Example: Son 

           12 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Declaration of Financial Status – Juvenile Court 

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5. 
(If you know your hourly wage, multiply that amount by the number of hours per week you work. Multiply 

Monthly Income  

that number by four to get your monthly income.) 

(For income that changes from month to month, calculate the annual total and divide by 12 months to list 

a monthly average.) 

Source of income 

Source of income 

Monthly 
amount 

Monthly 
amount 

[  ]  I am employed    [  ]  full-time    [  ]  part-time. 
[  ]  I am unemployed.  

Employment  

. 

  4

Work   
(Including self employment, 
wages, salaries, commissions, 
bonuses, tips and overtime) 

Rental income 

Dividends 

Retirement income (Including 
pensions, 401(k), IRA, etc.) 

Worker’s compensation 

Unemployment 

Child support 

Veteran’s benefits 

Alimony 

Public /government 
assistance (FEP, TANF, SSI, 
SSDI, welfare, etc.) 
Financial support from 
spouse, other household 
members and non-household 
members 

Trust or annuity income 

Other (Describe) 
 
Other (Describe) 
 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

Total monthly income  $ 

6. 

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

Monthly expense 

Monthly expense 

Current 
Amount 

Current 
Amount 

Rent or mortgage 

Food, clothing and household 
supplies 
Car payments, fuel, insurance 
and maintenance 
Other transportation costs  
(public transportation, parking, 
etc.) 
Utilities  (electricity, gas, water, 
sewer, garbage) 
Phone, internet and paid 
television (cable, satellite, 
streaming) 

Child support  

Child care 

Health care insurance and 
expenses 

Education (children or self) 

Alimony 

Garnishment or income 
withholding order 

$ 

$ 

$ 

$ 

$ 

$ 

200JUF Approved September 9, 2019 

Declaration of Financial Status – Juvenile Court 

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$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

$ 

Credit card payments 

$ 

Loans and other debt payments  $ 

$ 

Other (describe) 
 
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 

Home  

Land 

Cars 

Bank accounts 

Personal property  

Other (describe) 
 

finances: 

     

8. 

Other 

 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 

 

 

200JUF Approved September 9, 2019 

Declaration of Financial Status – Juvenile Court 

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Date