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Sample STATEMENT OF NET WORTH (for educational purpose only …not to be used in litigation)

 ________________ 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:

1)       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 prior marriage: _____Husband _____Wife

i)           (Husband)(Wife) (paying)(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 _________________

2.

2)       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             _______          4. Condominium charges             _______

2. Mortgage and                                                                           5. Cooperative apartment

amortization                      _______                                              maintenance                            _______

3. Real estate taxes                  _______

Total:  Housing       $_________

b)       Utilities

1. Fuel oil                                _______                                       4. Telephone                                  _______

2. Gas              _______          5. Water                                                                                        _______

3. Electricity    _______

Total:  Utilities                                   $_________

c)        Food

1. Groceries     _______          5. Liquor/alcohol                                                             _______

2. School lunches                    _______                                       6. Home entertainment                  _______

3. Lunches at work                  _______                                       7. Other ____________                 _______

4. Dining Out  _______

Total:  Food                                       $_________

d)       Clothing

1. Husband                              _______                                       3. Children                                     _______

2. Wife            _______          4. Other __________                                                      _______

Total:  Clothing                                  $_________

e)        Laundry

1. Laundry at home                 _______                                       3. Other __________              _______

2. Dry cleaning                        _______

Total:  Laundry                                  $_________

f)        Insurance

1. Life              _______          6. Medical plan                                                                              _______

2. Homeowner’s/tenant’s _______                                               7. Dental plan                                 _______

3. Fire, theft and                                                                           8. Optical plan                                _______

liability                       _______                                       9. Disability                                   _______

4. Automotive _______          10. Worker’s Compensation         _______

5. Umbrella policy                  _______                                       11. Other __________                   _______

Total:  Insurance                                $_________

g)       Unreimbursed medical

1. Medical                               _______                                       5. Surgical, nursing,

2. Dental                                  _______                                               hospital                                  _______

3. Optical                                 _______                                       6. Other __________               _______

4. Pharmaceutical                  _______

Total: Unreimbursed medical            $_________

h)       Household maintenance

1. Repairs                                _______                                       5. Painting                                      _______

2. Furniture, furnishings       6. Sanitation/carting                                                         _______

housewares         _______                                             7. Gardening/landscaping        _______

3. Cleaning supplies              _______                                       8. Snow removal                           _______

4. Appliances, including        9. Extermination                                                                            _______

maintenance              _______                                       10. Other __________                   ________

Total:  Household maintenance $________

i)        Household help

1. Babysitter                                _______                                   3. Other __________               _______

2. Domestic (housekeeper, maid, etc.) ________

Total:  Household help             $_________

j)        Automotive

Year:_______  Make:___________________                             Personal: _________________     Business: _______________

Year:_______  Make:___________________                             Personal: _________________     Business: _______________

Year:_______  Make:___________________                             Personal: _________________     Business: _______________

1. Payments    _______              4. Car wash                                                                               _______

2. Gas and oil  _______              5. Registration and license        _______

3. Repairs                                    _______                                   6. Parking and tolls                  _______

7. Other                                          _______

Total:  Automotive  $_________

k)       Educational

1. Nursery and pre-school           ______                                     6. School transportation                 _______

2. Primary and secondary           ______                                     7. School supplies/books               _______

3. College                                    ______                                     8. Tutoring                                     _______

4. Post-graduate                          ______                                     9. School events                             _______

5. Religious instruction               ______                                     10. Other _________              _______

Total:  Educational   $_________

l)        Recreational

1. Summer camp                        ______                                     9. Country club/pool club        _______

2. Vacations    ______                10. Health club                                                                          _______

3. Movies                                    ______                                     11. Sporting goods                  _______

4. Theatre, ballet, etc.                   ______                                     12. Hobbies                                   _______

5. Video rentals                           ______                                     13. Music/dance lessons                _______

6. Tapes, CD’s, etc.                     ______                                     14. Sports lessons                    _______

7. Cable television                       ______                                     15. Birthday parties                  _______

8. Team sports                            ______                                     16. Other ____________               _______

Total:  Recreational  $_________

m)      Income taxes

1. Federal                                    ______                                     3. City                                            _______

2. State            ______                4. Social Security and                                                  _______

Medicare

Total:  Income taxes                           $_________

n)       Miscellaneous

1. Beauty parlor/barber                _______                                   9. Union and organi-

2. Beauty aids/cosmetics,                                                                    zation dues                              _______

drug items                            _______                                   10. Commutation and

transportation                    _______

3. Cigarettes/tobacco                   _______                                   11. Veterinarian/pet expenses_______

4. Books, magazines,                                                                   12. Child support payments

newspapers                           _______                                         (prior marriage)                 _______

5. Children’s allowances              _______                                   13. Alimony and maintenance payments

6. Gifts            _______                  (prior marriage)                                                       _______

7. Charitable contributions          _______                                   14. Loan payments                  _______

8. Religious organization             15. Unreimbursed business

dues                            _______                                          expenses                                 _______

Total:  Miscellaneous                         $_________

o)       Other

1. _______________                  _______                                  3. _________________                 _______

2. _______________                  _______                                  4. _________________                 _______

Total:  Other                                       $_________

TOTAL EXPENSES:  $_________________

3)       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

(principal distribution and income)………..                               _______

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: &_________

4)       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. Financial institution _________________________________

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 _____________________________________

e. Source of funds______________________________________

f. Date of deposit ______________________________________

g. 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 and address 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 LIABILITIES:                                                                    (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                                             Date of

of Property                                                         Transferee                                                      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:

_________________________________________________________________________________

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(d) Deponent requires the services of an appraiser for the following reasons:

_________________________________________________________________________________

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X.      Other data concerning the financial circumstances of the parties that should be brought to the attention of the Court are:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

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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.

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(Petitioner)              (Respondent)

(Plaintiff)                 (Defendant)

Sworn to before me this

day of        , 20

____________________

       Notary Public

 

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           SIGNATURE OF ATTORNEY

 

 

 

__________________________________________

   ATTORNEYS NAME (PRINT OR TYPE)

___________________________________________

___________________________________________

___________________________________________

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ATTORNEYS ADDRESS & TELEPHONE NUMBER

ATTORNEY ADVERTISING: Information herein and is not intended to be, legal advice. This sample legal document is provided as part of a free educational service by Zachary Irtaza Riyaz, Esq., attorney at law in the State of New York (Westhampton – Tel. 516-234-0348), for reference only. Statutes and codes such as Domestic Relations Law (DRL)are frequently amended and may affect the validity of the above legal document and no representation is made that the above sample is going to be enforceable in the future. Updated statutes and codes may be available at the New York State Legislature Website. No statute or sample legal document should be relied on without understanding controlling case law which may further interpret it. AN ATTORNEY SHOULD BE CONSULTED FOR LEGAL ADVICE.

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