INCOME AND EXPENSE DECLARATION
Judicial Council Form FL-150
SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO — FAMILY LAW DIVISION
| Petitioner: | Elena Lopez |
| Respondent: | Carlos Lopez |
| Case Number: | 24DN012756 (FICTIONAL) |
| Date of Declaration: | March 3, 2026 |
PART 1 — EMPLOYMENT
| Field | Detail |
|---|---|
| Occupation | Dental Hygienist |
| Employer | Sunrise Dental Group (FICTIONAL), Chula Vista, CA |
| Employment Status | Part-time (3 days per week) |
| Date Employed | May 2019 |
| Address of Employer | [Fictional Address], Chula Vista, CA 91910 |
| Hours Per Week | 24 hours |
PART 2 — AVERAGE MONTHLY INCOME
(Gross amounts — before taxes and deductions)
| Income Source | Monthly Amount |
|---|---|
| Salary / Wages (part-time — see attached pay stubs) | $4,320.00 |
| Overtime | $0.00 |
| Commissions | $0.00 |
| Bonuses | $0.00 |
| Public Assistance (CalWORKs, TANF, etc.) | $0.00 |
| Spousal Support Received | $0.00 |
| Partner Support Received | $0.00 |
| Rental Income | $0.00 |
| Dividends / Interest | $42.00 |
| Trust Income | $0.00 |
| Other Income | $0.00 |
| TOTAL GROSS MONTHLY INCOME | $4,362.00 |
Paycheck Deductions (monthly):
| Deduction | Amount |
|---|---|
| Federal Income Tax | $420.00 |
| State Income Tax (CA) | $195.00 |
| FICA (Social Security + Medicare) | $333.00 |
| Health Insurance (COBRA) | $618.00 |
| Retirement (403b — currently suspended) | $0.00 |
| Total Deductions | $1,566.00 |
| ESTIMATED NET MONTHLY INCOME | $2,796.00 |
PART 3 — MONTHLY EXPENSES
Current actual expenses for petitioner and both minor children (Sofia, age 8; Mateo, age 5)
HOUSING
| Item | Monthly Amount |
|---|---|
| Mortgage (principal + interest) | $2,410.00 |
| Property Tax (1/12 annual) | $425.00 |
| Homeowner’s Insurance | $145.00 |
| Maintenance / Repairs (average) | $85.00 |
| HOA Dues | $0.00 |
| Housing Subtotal | $3,065.00 |
UTILITIES
| Item | Monthly Amount |
|---|---|
| Electricity / Gas | $180.00 |
| Water / Sewer | $65.00 |
| Telephone (cell) | $95.00 |
| Internet | $75.00 |
| Utilities Subtotal | $415.00 |
FOOD
| Item | Monthly Amount |
|---|---|
| Groceries | $820.00 |
| Restaurants / Takeout | $150.00 |
| Food Subtotal | $970.00 |
TRANSPORTATION
| Item | Monthly Amount |
|---|---|
| Vehicle Payment (2021 Honda CRV) | $385.00 |
| Auto Insurance | $195.00 |
| Gas | $220.00 |
| Vehicle Maintenance | $60.00 |
| Transportation Subtotal | $860.00 |
HEALTHCARE
| Item | Monthly Amount |
|---|---|
| Health Insurance Premium (COBRA — see Part 2) | $618.00 |
| Unreimbursed Medical Expenses (children, avg) | $145.00 |
| Dental / Vision (children) | $55.00 |
| Healthcare Subtotal | $818.00 |
CHILDREN’S EXPENSES
| Item | Monthly Amount |
|---|---|
| Childcare / Daycare (Sofia + Mateo, Bright Stars Learning Center) | $1,400.00 |
| School Supplies + Fees | $75.00 |
| Extracurricular Activities (soccer, art class) | $180.00 |
| Clothing (children, average) | $120.00 |
| Children’s Expenses Subtotal | $1,775.00 |
PERSONAL AND MISCELLANEOUS
| Item | Monthly Amount |
|---|---|
| Clothing (petitioner) | $80.00 |
| Laundry / Dry Cleaning | $25.00 |
| Personal Care / Grooming | $65.00 |
| Entertainment / Recreation | $90.00 |
| Subscriptions (streaming, etc.) | $35.00 |
| Personal Subtotal | $295.00 |
DEBT SERVICE
| Item | Monthly Amount |
|---|---|
| Credit Card (minimum payment — Visa ending XXXX) | $85.00 |
| Debt Service Subtotal | $85.00 |
SUMMARY
| Amount | |
|---|---|
| Total Monthly Expenses | $8,283.00 |
| Estimated Net Monthly Income | $2,796.00 |
| Monthly Deficit | ($5,487.00) |
Petitioner is currently drawing on joint savings to cover this monthly deficit. Joint savings account balance has declined from approximately $28,400 (at separation, October 2025) to approximately $12,600 as of the date of this declaration.
PART 4 — ATTESTATION
I declare under penalty of perjury under the laws of the State of California that the information contained in this Income and Expense Declaration is true and correct.
Elena Lopez, Petitioner Date: March 3, 2026
Attachments: Most recent 2 pay stubs; most recent 3 months bank statements; COBRA premium notice; childcare invoices (3 months); credit card statement.
This document is a fictional representation created for portfolio purposes only. All names, case numbers, and factual details are invented.