Get Family Financial Statement Form

Filling out the Family Financial Statement Form online is essential for determining parental fees based on financial capability. This guide will provide you with a step-by-step approach to accurately and efficiently complete the form, ensuring you provide all necessary information to the Department of Developmental Services.

Follow the steps to complete the Family Financial Statement Form online

1. Click ‘Get Form’ button to access the Family Financial Statement Form and open it in your preferred editing tool.
2. Begin with the 'Initial Determination' section. Include the required details such as date, regional center information, and the unique client identifier (UCI) number.
3. Fill in the client’s name, birth date, social security number, and date placed in care. Also, include the name and contact number of the placement facility.
4. In the 'Domestic' section, select and circle the appropriate relationship to the child (father, stepfather, or partner) and provide the personal data of the parent.
5. Next, input your home address, including street address, city, state, and zip code. Also, list your home phone number.
6. Proceed to the 'Your Job' section, indicating any relevant job information like position, employer, address, and business phone number. Mark any applicable status checkboxes, such as unemployed or deceased.
7. The 'Grandparent's Data' section requires similar address and contact information for the grandparent, if applicable.
8. In the 'Your Family Income' section, report gross income by source for each relevant individual, including monthly or annual amounts for salary, self-employed income, rental property income, and other streams.
9. Complete the 'Annual Amounts' section, inputting amounts for the client's medical expenses, health/dental insurance premiums, clothing expenses, personal needs, and transportation expenses.
10. Finally, review the entire form for accuracy. Save your changes, download, print, or share the completed Family Financial Statement Form as required.

Complete your Family Financial Statement Form online today for a seamless submission process.