COURT |
COUNTY OF | Index No. |
Plaintiff, | STATEMENT OF |
- against - | NET WORTH (DRL § 236) |
Defendant. |
Date of commencement of action |
Complete all items, marking "NONE," "INAPPLICABLE" and "UNKNOWN," (if appropriate)
STATE OF COUNTY OF SS.:
________, the (Petitioner) (Respondent) (Plaintiff) (Defendant) herein, being duly sworn, deposes and says that the following is an accurate statement as of ________, of my net worth (assets of whatsoever kind and nature and wherever situated minus liabilities), statement of income from all sources and statement of assets transferred of whatsoever kind and nature and wherever situated:
I. FAMILY DATA: (a) Husband's age ________(c) Date married ________(d) Date (separated) (divorced) ________(e) Number of dependent children under 21 years ________(f) Names and ages of children ________
________
________
________
(g) Custody of children ________ Husband ________ Wife(h) Minor children of a prior marriage: ________ Husband ________ Wife(i)(Husband)
(e) All pleadings, briefs or memor and a which reproduce, paraphrase or disclose any documents which have previously been designated by a party as comprising or containing Confidential Information or "Highly Confidential - Attorney's Eyes-Only Information" shall identify such documents by the production number ascribed to them at the time of production.
(receiving) $________ as alimony (maintenance) and/or $ ________ child support in connection with prior marriage
(j) Custody of children of prior marriage: Name ____________
Address ____________
(k) Is marital residence occupied by Husband ________ Wife ________ Both ________(l) Husband's present address ____________
Wife's present address
____________
(m) Occupation of Husband ____________ Occupation of Wife ____________(n) Husband's employer ____________
(o) Wife's employer ____________
(p) Education, training and skills [Include dates of attainment of degrees, etc.] Husband ____________
Wife ____________
(q) Husband's health ____________(r) Wife's health ____________(s) Children's health ____________II. EXPENSES: (You may elect to list all expenses on a weekly basis or all expenses on a monthly basis, however, you must be consistent. If any items are paid on a monthly basis, divide by 4.3 to obtain weekly payments; if any items are paid on a weekly basis, multiply by 4.3 to obtain monthly payment. Attach additional sheet, if needed. Items included under "Other" should be listed separately with separate dollar amounts.) Expenses listed [ ] weekly [ ] monthly
(a) Housing 2. Mortgage and amortization ________3. Real estate taxes ________4. Condominium charges ________5. Cooperative apartment maintenance ________ Total: Housing $ ________
(b) Utilities 5. Water ________ Total: Utilities $ ________
(c) Food 2. School lunches ________3. Lunches at work ________5. Liquor/alcohol ________6. Home entertainment ________7. Other ________ ________ Total: Food $________
(d) Clothing 4. Other ________ ________ Total: Clothing $________
(e) Laundry 1. Laundry at home ________3. Other ________ ________ Total: Laundry $________
(f) Insurance 2. Homeowner's/tenant's ________3. Fire, theft and liability ________5. Umbrella policy ________10. Workers' compensation11. Other ________ ________ Total: Insurance $________
(g) Unreimbursed medical 4. Pharmaceutical ________5. Surgical, nursing, hospital ________6. Other ________ ________ Total: Unreimbursed medical $________
(h) Household maintenance 2. Furniture, furnishings, housewares ________3. Cleaning supplies ________4. Appliances, including maintenance ________6. Sanitation/carting ________7. Gardening/landscaping ________9. Extermination ________10. Other ________ ________ Total: Household maintenance $________
(i) Household help 2. Domestic (housekeeper, maid, etc.) ________3. Other ________ ________ Total: Household help $________
(j) Automotive Year: ________ Make: ________ Personal: ________ Business: ________
Year: ________ Make: ________ Personal: ________ Business: ________
Year: ________ Make: ________ Personal: ________ Business: ________
5. Registration and license ________6. Parking and tolls ________7. Other ________ Total: Automotive $________
(k) Educational 1. Nursery and pre-school ________2. Primary and secondary ________4. Post-graduate ________5. Religious instruction ________6. School transportation ________7. School supplies/books ________9. School events ________10. Other ________ ________ Total: Educational $________
(l) Recreational 4. Theatre, ballet, etc. ________5. Video rentals ________6. Tapes, CD's, etc. ________7. Cable television ________9. Country club/pool club ________11. Sporting goods ________13. Music/dance lessons ________14. Sports lessons ________15. Birthday parties ________16. Other ________ ________ Total: Recreational $________
(m) Income taxes 4. Social Security and Medicare ________ Total: Income taxes $________
(n) Miscellaneous 1. Beauty parlor/barber ________2. Beauty aids/cosmetics, drug items ________3. Cigarettes/tobacco ________4. Books, magazines, newspapers ________5. Children's allowances ________7. Charitable contributions ________8. Religious organization dues ________9. Union and organization dues ________10. Commutation and transportation ________11. Veterinarian/pet expenses ________12. Child support payments (prior marriage) ________13. Alimony and maintenance payments (prior marriage) ________14. Loan payments ________15. Unreimbursed business expenses ________ Total: Miscellaneous $________
(o) Other 4. ________ ________ Total: Other $________
TOTAL EXPENSES: ________
III. GROSS INCOME: (State source of income and annual amount. Attach additional sheet, if needed.) (a) Salary or wages: (State whether income has changed during the year preceding date of this affidavit ________. If so, set forth name and address of all employers during preceding year and average weekly wage paid by each. Indicate overtime earnings separately. Attach previous year's W-2 or income tax return.) ____________ ________
____________ ________
(b) Weekly deductions: 1. Federal tax ............ ________2. New York State tax ............ ________3. Local tax ............ ________4. Social Security ............ ________5. Medicare ............ ________6. Other payroll deductions (specify)............ ________(c) Social Security number ________(d) Number and names of dependents claimed: ________(e) Bonus, commissions, fringe benefits (use of auto, memberships, etc.) ............ ________
(f) Partnership, royalties, sale of assets (income and installment payments) ............ ________(g) Dividends and interest (state whether taxable or not) ............ ________(h) Real estate (income only) ............ ________(i) Trust, profit sharing and annuities (e) All pleadings, briefs or memor and a which reproduce, paraphrase or disclose any documents which have previously been designated by a party as comprising or containing Confidential Information or "Highly Confidential - Attorney's Eyes-Only Information" shall identify such documents by the production number ascribed to them at the time of production.
(j) Pension (income only) ............ ________(k) Awards, prizes, grants (state whether taxable) ............ ________(l) Bequests, legacies and gifts ............ ________(m) Income from all other sources (including alimony, maintenance or child support from prior marriage)............ ________(n) Tax preference items: 1. Long term capital gain deduction ............ ________2. Depreciation, amortization or depletion ............ ________3. Stock options -- excess of fair market value over amount paid ............ ________(o) If any child or other member of your household is employed, set forth name and that person's annual income ............ ________(p) Social Security ............ ________(q) Disability benefits ............ ________(r) Public assistance ............ ________(s) Other ............ ________TOTAL INCOME: ________
IV. ASSETS. (If any asset is held jointly with spouse or another, so state, and set forth your respective shares. Attach additional sheets, if needed.)A. Cash accounts Cash
1.1b. Source of funds ____________c. Amount ____________ $________ Total: Cash $________
Checking accounts
2.1b. Account number ____________c. Title holder ____________d. Date opened ____________e. Source of funds ____________f. Balance ____________ $________ 2.2a. Financial institution ____________b. Account number ____________c. Title holder ____________d. Date opened ____________e. Source of funds ____________f. Balance ____________ $________ Total: Checking $________
Savings accounts (including individual, joint, totten trust, certificates of deposit, treasury notes)
3.1a. Financial institution ____________b. Account number ____________c. Title holder ____________d. Type of account ____________e. Date opened ____________f. Source of funds ____________g. Balance ____________ $________ 3.2a. Financial institution ____________b. Account number ____________c. Title holder ____________d. Type of account ____________e. Date opened ____________f. Source of funds ____________g. Balance ____________ $________ Total: Savings $________
Security deposits, earnest money, etc.
4.1b. Title owner ____________c. Type of deposit ____________d. Source of funds ____________e. Date of deposit ____________f. Amount ____________ $________ Total: Security deposits, etc. $________
Other
5.1b. Title owner ____________c. Type of account ____________d. Source of funds ____________e. Date of deposit ____________f. Amount ____________ $________ Total: Other $________
Total: Cash accounts $________
B. Securities Bonds, notes, mortgages
1.1a. Description of security ____________b. Title holder ____________d. Date of acquisition ____________e. Original price or value ____________f. Source of funds to acquire ____________g. Current value $________ Total: Bonds, notes, etc. $________
Stocks, options and commodity contracts
2.1a. Description of security ____________b. Title holder ____________d. Date of acquisition ____________e. Original price or value ____________f. Source of funds to acquire ____________g. Current value ____________ $________ 2.2a. Description of security ____________b. Title holder ____________d. Date of acquisition ____________e. Original price or value ____________f. Source of funds to acquire ____________g. Current value ____________ $________ 2.3a. Description of security ____________b. Title holder ____________d. Date of acquisition ____________e. Original price or value ____________f. Source of funds to acquire ____________g. Current value ____________ $________ Total: Stocks, options, etc. $________
Broker margin accounts
3.1a. Name and address of broker ____________b. Title holder ____________c. Date account opened ____________d. Original value of account ____________e. Source of funds ____________f. Current value ____________ $________ Total: Margin accounts $________
Total: Value of securities: $________
C. Loans to others and accounts receivable 1.1a. Debtor's name and address ____________b. Original amount of loan or debt ____________c. Source of funds from which loan made or origin of debt ____________d. Date payment(s) due ____________e. Current amount due ____________ $________ 1.2a. Debtor's name and address ____________b. Original amount of loan or debt ____________c. Source of funds from which loan made or origin of debt ____________d. Date payment(s) due ____________e. Current amount due ____________ $________ Total: Loans and accounts receivable $________
D. Value of interest in any business 1.1a. Name and address of business ____________b. Type of business (corporate, partnership, sole proprietorship or other) ____________c. Your capital contribution ____________d. Your percentage of interest e. Date of acquisition ____________f. Original price or value ____________g. Source of funds to acquire ____________h. Method of valuation ____________i. Other relevant information ____________j. Current net worth of business ____________ $ ________ Total: Value of business interest $________
E. Cash surrender value of life insurance 1.1a. Insurer's name and address ____________b. Name of insured ____________c. Policy number ____________d. Face amount of policy ____________e. Policy owner ____________f. Date of acquisition ____________g. Source of funding to acquire ____________h. Current cash surrender value ____________ $________ Total: Value of life insurance $________
F. Vehicles (automobile, boat, plane, truck, camper, etc.) 1.1a. Description ____________b. Title owner ____________c. Date of acquisition ____________d. Original price ____________e. Source of funds to acquire ____________f. Amount of current lien unpaid ____________g. Current fair market value ____________ $________ 1.2a. Description ____________b. Title owner ____________c. Date of acquisition ____________d. Original price ____________e. Source of funds to acquire ____________f. Amount of current lien unpaid ____________g. Current fair market value ____________ $________ Total: Value of vehicles $________
G. Real estate (including real property, leaseholds, life estates, etc. at market value--do not deduct any mortgage) 1.1a. Description ____________b. Title owner ____________c. Date of acquisition ____________d. Original price ____________e. Source of funds to acquire ____________f. Amount of mortgage or lien unpaid ____________g. Estimated current market value ____________ $________ 1.2a. Description ____________b. Title owner ____________c. Date of acquisition ____________d. Original price ____________e. Source of funds to acquire ____________f. Amount of mortgage or lien unpaid ____________g. Estimated current market value ____________ $________ 1.3a. Description ____________b. Title owner ____________c. Date of acquisition ____________d. Original price ____________e. Source of funds to acquire ____________f. Amount of mortgage or lien unpaid ____________g. Estimated current market value ____________ $________ Total: Value of real estate $________
H. Vested interests in trusts (pension, profit sharing, legacies, deferred compensation and others) 1.1a. Description of trust ____________b. Location of assets ____________c. Title owner ____________d. Date of acquisition ____________e. Original investment ____________f. Source of funds ____________g. Amount of unpaid liens ____________h. Current value ____________ $________ 1.2a. Description of trust ____________b. Location of assets ____________c. Title owner ____________d. Date of acquisition ____________e. Original investment ____________f. Source of funds ____________g. Amount of unpaid liens ____________h. Current value ____________ $________ Total: Vested interest in trusts $________
I. Contingent interests (stock options, interests subject to life estates, prospective inheritances, etc.) 1.1a. Description ____________c. Date of vesting ____________d. Title owner ____________e. Date of acquisition ____________f. Original price or value ____________g. Source of funds to acquire ____________h. Method of valuation ____________i. Current value ____________ $________ Total: Contingent interests $________
J. Household furnishings 1.1a. Description ____________c. Title owner ____________d. Original price ____________e. Source of funds to acquire ____________f. Amount of lien unpaid ____________g. Current value ____________ $________ Total: Household furnishings $________
K. Jewelry, art, antiques, precious objects, gold and precious metals (only if valued at more than $500) 1.1a. Description ____________b. Title owner ____________d. Original price or value ____________e. Source of funds to acquire ____________f. Amount of lien unpaid ____________g. Current value ____________ $________ 1.2a. Description ____________b. Title owner ____________d. Original price or value ____________e. Source of funds to acquire ____________f. Amount of lien unpaid ____________g. Current value ____________ $________ Total: Jewelry, art, etc.: $________
L. Other (e.g., tax shelter investments, collections, judgments, causes of action, patents, trademarks, copyrights, and any other asset not hereinabove itemized) 1.1a. Description ____________b. Title owner ____________d. Original price or value ____________e. Source of funds to acquire ____________f. Amount of lien unpaid ____________g. Current value ____________ $________ 1.2a. Description ____________b. Title owner ____________d. Original price or value ____________e. Source of funds to acquire ____________f. Amount of lien unpaid ____________g. Current value ____________ $________ Total: Other $________
TOTAL: ASSETS $________
V. LIABILITIES A. Accounts payable 1.1a. Name and address of creditor ____________c. Amount of original debt ____________d. Date of incurring debt ____________f. Monthly or other periodic payment ____________g. Amount of current debt ____________ $________ 1.2a. Name and address of creditor ____________c. Amount of original debt ____________d. Date of incurring debt ____________f. Monthly or other periodic payment ____________g. Amount of current debt ____________ $________ 1.3a. Name and address of creditor ____________c. Amount of original debt ____________d. Date of incurring debt ____________f. Monthly or other periodic payment ____________g. Amount of current debt ____________ $________ 1.4a. Name and address of creditor ____________c. Amount of original debt ____________d. Date of incurring debt ____________f. Monthly or other periodic payment ____________g. Amount of current debt ____________ $________ 1.5a. Name and address of creditor ____________c. Amount of original debt ____________d. Date of incurring debt ____________f. Monthly or other periodic payment ____________g. Amount of current debt ____________ $________ Total: Accounts payable $________
B. Notes payable 1.1a. Name and address of note holder ____________c. Amount of original debt ____________d. Date of incurring debt ____________f. Monthly or other periodic payment ____________g. Amount of current debt ____________ $________ 1.2a. Name and address of note holder ____________c. Amount of original debt ____________d. Date of incurring debt ____________f. Monthly or other periodic payment ____________g. Amount of current debt ____________ $________ Total: Notes payable $________
C. Installment accounts payable (security agreements, chattel mortgages) 1.1.a. Name and address of creditor ____________c. Amount of original debt ____________d. Date of incurring debt ____________f. Monthly or other periodic payment ____________g. Amount of current debt ____________ $________ 1.2a. Name and address of creditor ____________c. Amount of original debt ____________d. Date of incurring debt ____________f. Monthly or other periodic payment ____________g. Amount of current debt ____________ $________ Total: Installment accounts $________
D. Brokers' margin accounts 1.1a. Name and address of broker ____________b. Amount of original debt ____________c. Date of incurring debt ____________e. Monthly or other periodic payment ____________f. Amount of current debt ____________ $________ Total: Brokers' margin accounts $________
E. Mortgages payable on real estate 1.1a. Name and address of mortgagee ____________b. Address of property mortgaged ____________c. Mortgagor(s) ____________d. Original debt ____________e. Date of incurring debt ____________f. Monthly or other periodic payment ____________g. Maturity date ____________h. Amount of current debt ____________ $________ 1.2a. Name and address of mortgagee ____________b. Address of property mortgaged ____________c. Mortgagor(s) ____________d. Original debt ____________e. Date of incurring debt ____________f. Monthly or other periodic payment ____________g. Maturity date ____________h. Amount of current debt ____________ $________ Total: Mortgages payable $________
F. Taxes payable 1.1a. Description of tax ____________b. Amount of tax ____________c. Date due ____________ Total: Taxes payable $________
G. Loans on life insurance policies 1.1a. Name of insurer ____________b. Amount of loan ____________c. Date incurred ____________e. Name of borrower ____________f. Monthly or other periodic payment ____________g. Amount of current debt ____________ $________ Total: Life insurance loans $________
H. Other liabilities 1.1a. Description ____________b. Name and address of creditor ____________d. Original amount of debt ____________e. Date incurred ____________g. Monthly or other periodic payment ____________h. Amount of current debt ____________ $________ 1.2a. Description ____________b. Name and address of creditor ____________d. Original amount of debt ____________e. Date incurred ____________g. Monthly or other periodic payment ____________h. Amount of current debt ____________ $________ Total: Other liabilities $________
TOTAL LIABILITIES: $________
NET WORTH
TOTAL ASSETS: $________
TOTAL LIABLITIES: (minus) ($________)
NET WORTH: $________
VI. ASSETS TRANSFERRED: (List all assets transferred in any manner during the preceding three years, or length of the marriage, whichever is shorter [transfers in the routine course of business which resulted in an exchange of assets of substantially equivalent value need not be specifically disclosed where such assets are otherwise identified in the statement of net worth].) To whom transferred
Description and relationship to of property transferee Date of transfer Value
________ ________ ________ ________
________ ________ ________ ________
________ ________ ________ ________
________ ________ ________ ________
VII. SUPPORT REQUIREMENTS: (a) Deponent is at present (paying)(receiving) $ ________ per (week)(month), and prior to separation (paid)(received) $ ________ per (week)(month), to cover expenses for ____________ ____________.
These payments are being made (voluntarily)(pursuant to court order or judgment)(pursuant to separation agreement), and there are (no) arrears outstanding (in the sum of $ ________ to date).
(b) Deponent requests for support of each child $ ________ per (week)(month). Total for children $ ________.(c) Deponent requests for support of self $ ________ per (week)(month).(d) The day of the (week)(month) on which payment should be made is ________.VIII. COUNSEL FEE REQUIREMENTS: (a) Deponent requests for counsel fee and disbursements the sum of $ ________.(b) Deponent has paid counsel the sum of $ ________ and has agreed with counsel concerning fees as follows: ____________
____________
____________
(c) There is (not) a retainer agreement or written agreement relating to payment of legal fees. (A copy of any such agreement must be annexed.)IX. ACCOUNTANT AND APPRAISAL FEES REQUIREMENTS:(a) Deponent requests for accountants' fees and disbursements the sum of $ ________. (Include basis for fee, e.g., hourly rate, flat rate.)(b) Deponent requests for appraisal fees and disbursements the sum of $ ________ . (Include basis for fee, e.g., hourly rate, flat rate.)(c) Deponent requires the services of an accountant for the following reasons: ____________
____________
(d) Deponent requires the services of an appraiser for the following reasons: ____________
____________
X. Other data concerning the financial circumstances of the parties that should be brought to the attention of the Court are: ____________
____________
________________________
____________
____________
____________
The foregoing statements and a rider consisting of ________ page(s) annexed hereto and made part hereof, have been carefully read by the undersigned who states that they are true and correct.
____________
(Petitioner)
(Respondent)
(Plaintiff)
(Defendant)
Sworn to before me this
________ day of ________, 19________
______________
SIGNATURE OF ATTORNEY
______________
ATTORNEY'S NAME (PRINT OR TYPE
________
________
________
______________
ATTORNEY'S ADDRESS AND TELE-
PHONE NUMBER
N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. III, subch. A, Statement of net worth (DRL 236)