Current through Register Vol. 46, No. 12, March 20, 2024
|
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 ________
(b) Wife'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
1. Rent ________
2. Mortgage and amortization
________
3. Real
estate taxes ________
4. Condominium charges
________
5.
Cooperative apartment maintenance ________
Total: Housing $ ________
(b) Utilities
1. Fuel Oil ________
2. Gas ________
3. Electricity
________
4.
Telephone ________
5. Water ________
Total: Utilities $ ________
(c) Food
1. Groceries
________
2. School
lunches ________
3.
Lunches at work ________
4. Dining out ________
5. Liquor/alcohol
________
6. Home
entertainment ________
7. Other ________ ________
Total: Food $________
(d) Clothing
1. Husband ________
2. Wife ________
3. Children ________
4. Other ________ ________
Total: Clothing $________
(e) Laundry
1. Laundry at home
________
2. Dry
cleaning ________
3.
Other ________ ________
Total: Laundry $________
(f) Insurance
1. Life ________
2. Homeowner's/tenant's
________
3. Fire,
theft and liability ________
4. Automotive ________
5. Umbrella policy
________
6. Medical
plan ________
7.
Dental plan ________
8. Optical plan ________
9. Disability
________
10.
Workers' compensation
11. Other ________ ________
Total: Insurance $________
(g) Unreimbursed
medical
1. Medical
________
2. Dental
________
3. Optical
________
4.
Pharmaceutical ________
5. Surgical, nursing, hospital
________
6. Other
________ ________
Total: Unreimbursed medical $________
(h)
Household maintenance
1.
Repairs ________
2.
Furniture, furnishings, housewares ________
3. Cleaning supplies ________
4. Appliances, including
maintenance ________
5. Painting ________
6. Sanitation/carting
________
7.
Gardening/landscaping ________
8. Snow removal ________
9. Extermination
________
10. Other
________ ________
Total: Household maintenance
$________
(i) Household help
1. Babysitter
________
2. Domestic
(housekeeper, maid, etc.) ________
3. Other ________ ________
Total: Household help $________
(j)
Automotive
Year: ________ Make: ________ Personal:
________ Business: ________
Year: ________ Make: ________ Personal:
________ Business: ________
Year: ________ Make: ________ Personal:
________ Business: ________
1. Payments ________
2. Gas and oil
________
3. Repairs
________
4. Car wash
________
5.
Registration and license ________
6. Parking and tolls ________
7. Other ________
Total: Automotive $________
(k)
Educational
1. Nursery and
pre-school ________
2. Primary and secondary
________
3. College
________
4.
Post-graduate ________
5. Religious instruction
________
6. School
transportation ________
7. School supplies/books
________
8. Tutoring
________
9. School
events ________
10.
Other ________ ________
Total: Educational $________
(l)
Recreational
1. Summer camp
________
2.
Vacations ________
3. Movies ________
4. Theatre, ballet, etc.
________
5. Video
rentals ________
6.
Tapes, CD's, etc. ________
7. Cable television ________
8. Team sports
________
9. Country
club/pool club ________
10. Health club ________
11. Sporting goods
________
12. Hobbies
________
13.
Music/dance lessons ________
14. Sports lessons ________
15. Birthday parties
________
16. Other
________ ________
Total: Recreational $________
(m)
Income taxes
1. Federal
________
2. State
________
3. City
________
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 ________
6. Gifts ________
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
1. ________
________
2. ________
________
3. ________
________
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
1.1
a.
Location ____________
b. Source of funds
____________
c.
Amount ____________ $________
Total: Cash $________
Checking accounts
2.1
a.
Location ____________
b. Account number
____________
c.
Title holder ____________
d. Date opened ____________
e. Source of funds
____________
f.
Balance ____________ $________
2.2
a.
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)
3.1
a. Financial institution
____________
b.
Account number ____________
c. Title holder ____________
d. Type of account
____________
e. Date
opened ____________
f. Source of funds
____________
g.
Balance ____________ $________
3.2
a.
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.
4.1
a. Location ____________
b. Title owner
____________
c. Type
of deposit ____________
d. Source of funds
____________
e. Date
of deposit ____________
f. Amount ____________ $________
Total: Security deposits, etc.
$________
Other
5.1
a.
Location ____________
b. 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
1.1
a.
Description of security ____________
b. Title holder ____________
c. Location
____________
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
2.1
a. Description of security
____________
b.
Title holder ____________
c. Location ____________
d. Date of acquisition
____________
e.
Original price or value ____________
f. Source of funds to acquire
____________
g.
Current value ____________ $________
2.2
a. Description of security
____________
b.
Title holder ____________
c. Location ____________
d. Date of acquisition
____________
e.
Original price or value ____________
f. Source of funds to acquire
____________
g.
Current value ____________ $________
2.3
a.
Description of security ____________
b. Title holder ____________
c. Location
____________
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
3.1
a. 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
1.1
a. 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 ____________ $________
1.2
a.
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
1.1
a. 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
1.1
a. 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.)
1.1
a. 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 ____________ $________
1.2
a.
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)
1.1
a. 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 ____________ $________
1.2
a.
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 ____________ $________
1.3
a.
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)
1.1
a.
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 ____________ $________
1.2
a. 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.)
1.1
a.
Description ____________
b. Location ____________
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
1.1
a.
Description ____________
b. Location ____________
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)
1.1
a.
Description ____________
b. Title owner ____________
c. Location
____________
d.
Original price or value ____________
e. Source of funds to acquire
____________
f.
Amount of lien unpaid ____________
g. Current value ____________ $________
1.2
a. Description ____________
b. Title owner
____________
c.
Location ____________
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)
1.1
a.
Description ____________
b. Title owner ____________
c. Location
____________
d.
Original price or value ____________
e. Source of funds to acquire
____________
f.
Amount of lien unpaid ____________
g. Current value ____________ $________
1.2
a. Description ____________
b. Title owner
____________
c.
Location ____________
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
1.1
a. Name
and address of creditor ____________
b. Debtor ____________
c. Amount of original debt
____________
d. Date
of incurring debt ____________
e. Purpose ____________
f. Monthly or other periodic
payment ____________
g. Amount of current debt ____________
$________
1.2
a. Name and address of creditor
____________
b.
Debtor ____________
c. Amount of original debt
____________
d. Date
of incurring debt ____________
e. Purpose ____________
f. Monthly or other periodic
payment ____________
g. Amount of current debt ____________
$________
1.3
a. Name and address of creditor
____________
b.
Debtor ____________
c. Amount of original debt
____________
d. Date
of incurring debt ____________
e. Purpose ____________
f. Monthly or other periodic
payment ____________
g. Amount of current debt ____________
$________
1.4
a. Name and address of creditor
____________
b.
Debtor ____________
c. Amount of original debt
____________
d. Date
of incurring debt ____________
e. Purpose ____________
f. Monthly or other periodic
payment ____________
g. Amount of current debt ____________
$________
1.5
a. Name and address of creditor
____________
b.
Debtor ____________
c. Amount of original debt
____________
d. Date
of incurring debt ____________
e. Purpose ____________
f. Monthly or other periodic
payment ____________
g. Amount of current debt ____________
$________
Total: Accounts payable $________
B. Notes payable
1.1
a. Name
and address of note holder ____________
b. Debtor ____________
c. Amount of original debt
____________
d. Date
of incurring debt ____________
e. Purpose ____________
f. Monthly or other periodic
payment ____________
g. Amount of current debt ____________
$________
1.2
a. Name and address of note holder
____________
b.
Debtor ____________
c. Amount of original debt
____________
d. Date
of incurring debt ____________
e. Purpose ____________
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
____________
b.
Debtor ____________
c. Amount of original debt
____________
d. Date
of incurring debt ____________
e. Purpose ____________
f. Monthly or other periodic
payment ____________
g. Amount of current debt ____________
$________
1.2
a. Name and address of creditor
____________
b.
Debtor ____________
c. Amount of original debt
____________
d. Date
of incurring debt ____________
e. Purpose ____________
f. Monthly or other periodic
payment ____________
g. Amount of current debt ____________
$________
Total: Installment accounts $________
D. Brokers' margin accounts
1.1
a. Name
and address of broker ____________
b. Amount of original debt
____________
c. Date
of incurring debt ____________
d. Purpose ____________
e. Monthly or other periodic
payment ____________
f. Amount of current debt ____________
$________
Total: Brokers' margin accounts
$________
E. Mortgages payable on real estate
1.1
a. 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 ____________ $________
1.2
a. 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
1.1
a. Description of tax
____________
b.
Amount of tax ____________
c. Date due ____________
Total: Taxes payable $________
G. Loans on life insurance policies
1.1
a. Name
of insurer ____________
b. Amount of loan
____________
c. Date
incurred ____________
d. Purpose ____________
e. Name of borrower
____________
f.
Monthly or other periodic payment ____________
g. Amount of current debt
____________ $________
Total: Life insurance loans $________
H. Other liabilities
1.1
a.
Description ____________
b. Name and address of creditor
____________
c.
Debtor ____________
d. Original amount of debt
____________
e. Date
incurred ____________
f. Purpose ____________
g. Monthly or other periodic
payment ____________
h. Amount of current debt ____________
$________
1.2
a. Description ____________
b. Name and address of
creditor ____________
c. Debtor ____________
d. Original amount of debt
____________
e. Date
incurred ____________
f. Purpose ____________
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
