FL-150

PARTY WITHOUT ATTORNEY OR ATTORNEY STATE BAR NUMBER: FOR COURT USE ONLY
NAME: Sergei Zdorenko
FIRM NAME: N/A
STREET ADDRESS: 65 Pierce Ave, apt 305
CITY: San Jose STATE: CA ZIP CODE: 95110
TELEPHONE NO.: 267-690-1456 FAX NO.:
E-MAIL ADDRESS: [email protected]
ATTORNEY FOR (name): N/A

SUPERIOR COURT OF CALIFORNIA, COUNTY OF Santa Clara

STREET ADDRESS: 191 N First St
MAILING ADDRESS: 191 N First St
CITY AND ZIP CODE: San Jose, 95113
BRANCH NAME: Superior Court of Santa Clara County

PETITIONER: Sergei Zdorenko

RESPONDENT: Briana Van Buskirk
OTHER PARTY/PARENT/CLAIMANT:
CASE NUMBER:
INCOME AND EXPENSE DECLARATION

1. Employment (Give information on your current job or, if you're unemployed, your most recent job.)
a. Employer: HCL America Inc
Attach copies
b. Employer's address: 330 Potrero Ave, Sunnyvale, CA, 94085
of your pay
stubs for last c. Employer's phone number: 408-733-0480
two months d. Occupation: QA analyst
(black out e. Date job started: 05/31/2022
Social f. If unemployed, date job ended: 3/19/2024
Security g. I work about 40 hours per week.
numbers). h. I get paid $ 50 gross (before taxes) per month per week ✖ per hour.
(If you have more than one job, attach an 8 1/2-by-11-inch sheet of paper and list the same information as above for your other
jobs. Write "Question 1—Other Jobs" at the top.)

2. Age and education

a. My age is (specify): 31
b. I have completed high school or the equivalent: ✖ Yes No If no, highest grade completed (specify):
c. Number of years of college completed (specify): 5 ✖ Degree(s) obtained (specify): Bachelor's degree
d. Number of years of graduate school completed (specify): N/A Degree(s) obtained (specify): N/A
e. I have: professional/occupational license(s) (specify):
vocational training (specify):
3. Tax information
a. ✖ I last filed taxes for tax year (specify year): 2024
b. My tax filing status is single head of household ✖ married, filing separately
married, filing jointly with (specify name):
c. I file state tax returns in ✖ California other (specify state):
d. I claim the following number of exemptions (including myself) on my taxes (specify):
4. Other party's income. I estimate the gross monthly income (before taxes) of the other party in this case at (specify): $ 70000
This estimate is based on (explain): her information
(If you need more space to answer any questions on this form, attach an 8 1/2-by-11-inch sheet of paper and write the
question number before your answer.) Number of pages attached: 0
I declare under penalty of perjury under the laws of the State of California that the information contained on all pages of this form and
any attachments is true and correct.
Date:

(TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT)

Page 1 of 4

Form Adopted for Mandatory Use INCOME AND EXPENSE DECLARATION Family Code, §§ 2030–2032, 2100–2113,
Judicial Council of California 3552, 3620–3634, 4050–4076, 4300–4339
FL-150 [Rev. January 1, 2019] www.courts.ca.gov
 FL-150
PETITIONER: Sergei Zdorenko CASE NUMBER:

RESPONDENT: Briana Van Buskirk

OTHER PARTY/PARENT/CLAIMANT:

Attach copies of your pay stubs for the last two months and proof of any other income. Take a copy of your latest federal tax
return to the court hearing. (Black out your Social Security number on the pay stub and tax return.)

5. Income (For average monthly, add up all the income you received in each category in the last 12 months Average
and divide the total by 12.)
Last month monthly
a. Salary or wages (gross, before taxes)..................................................................................................... $ 0 0
b. Overtime (gross, before taxes)................................................................................................................ $ 0 0
c. Commissions or bonuses......................................................................................................................... $ 0 0
d. Public assistance (for example: TANF, SSI, GA/GR) currently receiving .................................. $
e. Spousal support from this marriage from a different marriage federally taxable* $
f. Partner support from this domestic partnership from a different domestic partnership $
g. Pension/retirement fund payments.......................................................................................................... $ 583 583
h. Social Security retirement (not SSI)......................................................................................................... $
i. Disability: Social Security (not SSI) State disability (SDI) Private insurance $
j. Unemployment compensation................................................................................................................. $ 0 0
k. Workers' compensation............................................................................................................................ $ 0 0
l. Other (military allowances, royalty payments) (specify): $ 0 0

6. Investment income (Attach a schedule showing gross receipts less cash expenses for each piece of property.)
a. Dividends/interest.................................................................................................................................... $ Apple 120
b. Rental property income........................................................................................................................... $
c. Trust income............................................................................................................................................ $
d. Other (specify): $

7. Income from self-employment, after business expenses for all businesses......................................... $

I am the owner/sole proprietor business partner other (specify):
Number of years in this business (specify):
Name of business (specify):
Type of business (specify):
Attach a profit and loss statement for the last two years or a Schedule C from your last federal tax return. Black out your
Social Security number. If you have more than one business, provide the information above for each of your businesses.

8. Additional income. I received one-time money (lottery winnings, inheritance, etc.) in the last 12 months (specify source and
amount):

9. ✖ Change in income. My financial situation has changed significantly over the last 12 months because (specify):
I lost my job
10. Deductions Last month
a. Required union dues.................................................................................................................................................... $
b. Required retirement payments (not Social Security, FICA, 401(k), or IRA).................................................................. $
c. Medical, hospital, dental, and other health insurance premiums (total monthly amount)............................................. $ 70
d. Child support that I pay for children from other relationships....................................................................................... $
e. Spousal support that I pay by court order from a different marriage federally tax deductible*.......................... $
f. Partner support that I pay by court order from a different domestic partnership.......................................................... $
g. Necessary job-related expenses not reimbursed by my employer (attach explanation labeled "Question 10g")......... $

11. Assets Total

a. Cash and checking accounts, savings, credit union, money market, and other deposit accounts............................... $ 51500
b. Stocks, bonds, and other assets I could easily sell.......................................................................................................$ 1450
c. All other property, real and ✖ personal (estimate fair market value minus the debts you owe)..... $ 3500

* Check the box if the spousal support order or judgment was executed by the parties and the court before January 1, 2019, or if a court-ordered change
maintains the spousal support payments as taxable income to the recipient and tax deductible to the payor.

FL-150 [Rev. January 1, 2019] INCOME AND EXPENSE DECLARATION Page 2 of 4

 FL-150
PETITIONER: Sergei Zdorenko CASE NUMBER:

RESPONDENT: Briana Van Buskirk

OTHER PARTY/PARENT/CLAIMANT:

12. The following people live with me:

How the person is That person's gross Pays some of the
Name Age related to me (ex: son) monthly income household expenses?
a. Yes No
b. Yes No
c. Yes No
d. Yes No
e. Yes No

13. Average monthly expenses ✖ Estimated expenses Actual expenses Proposed needs
a. Home: h. Laundry and cleaning..................................... $ 24
(1) ✖ Rent or mortgage.......... $ 2100 i. Clothes........................................................... $ 50
If mortgage: j. Education....................................................... $ 100
(a) average principal: $ k. Entertainment, gifts, and vacation.................. $ 400
(b) average interest: $ l. Auto expenses and transportation
(insurance, gas, repairs, bus, etc.)................. $ 270
(2) Real property taxes.................................. $
(3) Homeowner's or renter's insurance m. Insurance (life, accident, etc.; do not include
(if not included above).............................. $ auto, home, or health insurance)................... $
(4) Maintenance and repair........................... $ n. Savings and investments............................... $ 583
o. Charitable contributions.................................. $
b. Health-care costs not paid by insurance........ $ 60
p. Monthly payments listed in item 14
c. Child care....................................................... $
(itemize below in 14 and insert total here)..... $ 150
d. Groceries and household supplies................. $ 600 $
q. Other (specify):
e. Eating out....................................................... $ 200
r. TOTAL EXPENSES (a–q) (do not add in
f. Utilities (gas, electric, water, trash)................ $ the amounts in a(1)(a) and (b)) $ 4577
g. Telephone, cell phone, and e-mail................. $ 40 $
s. Amount of expenses paid by others

14. Installment payments and debts not listed above

Paid to For Amount Balance Date of last payment
$ $
$ $
$ $
$ $
$ $
$ $

15. Attorney fees (This information is required if either party is requesting attorney fees):
a. To date, I have paid my attorney this amount for fees and costs (specify): $
b. The source of this money was (specify):
c. I still owe the following fees and costs to my attorney (specify total owed): $
d. My attorney's hourly rate is (specify):
I confirm this fee arrangement.

Date:

(TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT)

FL-150 [Rev. January 1, 2019] INCOME AND EXPENSE DECLARATION Page 3 of 4

 FL-150
PETITIONER: Sergei Zdorenko CASE NUMBER:

RESPONDENT: Briana Van Buskirk

OTHER PARTY/PARENT/CLAIMANT:

CHILD SUPPORT INFORMATION

(NOTE: Fill out this page only if your case involves child support.)

16. Number of children

a. I have (specify number): children under the age of 18 with the other parent in this case.
b. The children spend percent of their time with me and percent of their time with the other parent.
(If you're not sure about percentage or it has not been agreed on, please describe your parenting schedule here.)

17. Children's health-care expenses

a. I do I do not have health insurance available to me for the children through my job.
b. Name of insurance company:
c. Address of insurance company:

d. The monthly cost for the children's health insurance is or would be (specify): $
(Do not include the amount your employer pays.)

18. Additional expense for the children in this case Amount per month
a. Childcare so I can work or get job training.................................................................... $
b. Children's health care not covered by insurance........................................................... $
c. Travel expenses for visitation........................................................................................ $
d. Children's educational or other special needs (specify below):..................................... $

19. Special hardships. I ask the court to consider the following special financial circumstances
(attach documentation of any item listed here, including court orders): Amount per month For how many months?
a. Extraordinary health expenses not included in 18b................................... $
b. Major losses not covered by insurance (examples: fire, theft, other
$
insured loss)...............................................................................................
c. (1) Expenses for my minor children who are from other relationships and
$
are living with me..................................................................................
(2) Names and ages of those children (specify):

(3) Child support I receive for those children............................................... $

The expenses listed in a, b, and c create an extreme financial hardship because (explain):

20. Other information I want the court to know concerning support in my case (specify):

FL-150 [Rev. January 1, 2019] INCOME AND EXPENSE DECLARATION Page 4 of 4

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