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Child support, Christian, Divorce, Family law, Husband, Marriage, Petitioner, Relationships, Sample STATEMENT OF NET WORTH (for educational purpose only ...not to be used in litigation)
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)
______________________________________________ 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:
_________________________________________________________________________________
_________________________________________________________________________________
(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 , 20
____________________
Notary Public
__________________________________________
SIGNATURE OF ATTORNEY
__________________________________________
ATTORNEYS NAME (PRINT OR TYPE)
___________________________________________
___________________________________________
___________________________________________
___________________________________________
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.
WesthamptonLawyer 