a.
b.
EMANCIPATION OF MINOR INCOME
AND EXPENSE DECLARATION
Form Adopted for Mandatory Use
Judicial Council of California
EM-115 [Rev. September 1, 2018]
Family Code, § 7000, et seq.
www.courts.ca.gov
Page 1 of 2
I am attending school (name of school and grade):
1. My name and address are:
My telephone number is:
I have been living at this address since:
I live there with (name and relationship of all persons, including children):
2. My date of birth is:
3.
I am not attending school. The highest year of education I have completed is:
4.
a.
b.
5.
I am employed. My place of employment is (name and address):
I started work there on (date):
I am not employed at the present time. I last worked from (starting month and year):
to (ending month and year):
My gross monthly earnings were: $
a.
b.
6.
c.
d.
I am not receiving welfare or AFDC and I do not intend to apply for welfare or AFDC.
I am receiving welfare or AFDC. Monthly amount received: $
I have applied for welfare or AFDC.
I intend to apply for welfare or AFDC.
My occupation is:
ATTORNEY OR PARTY WITHOUT ATTORNEY
STATE BAR NUMBER:
NAME:
FIRM NAME:
STREET ADDRESS:
CITY: STATE: ZIP CODE:
TELEPHONE NO.: FAX NO.:
E-MAIL ADDRESS:
ATTORNEY FOR (name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
Petitioner, a minor
IN THE MATTER OF (name):
EMANCIPATION OF MINOR INCOME AND
EXPENSE DECLARATION
FOR COURT USE ONLY
CASE NUMBER:
EM-115
AmountThe average of my gross monthly earnings is:
a.
b.
c.
Value
I have the following assets:
a.
b.
c.
d.
e.
f.
Amount
My monthly expenses are:9.
b.
c.
d.
e.
Loan payments
Rent or
Mortgage
Food
Clothing
Phone and utilities
Vehicle
(1)
(2) Maintenance
I declare under penalty of perjury that the foregoing is true and correct.
(SIGNATURE OF PETITIONER)
EM-115
CASE NUMBER:
IN THE MATTER OF (name):
8.
7.
$Salary and wages, including bonuses and overtime
Money received from parents or other adults assisting me
(name and relationship):
Other
$
$
Cash
Checking account
Savings account
Stocks, bonds
Vehicle
Other
$
$
$
$
$
$
a. $
$
$
$
$
$
$
(TYPE OR PRINT NAME)
Date:
EMANCIPATION OF MINOR INCOME
AND EXPENSE DECLARATION
EM-115 [Rev. September 1, 2018] Page 2 of 2
(specify):
(year, make, model):
(specify source and amount):
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