14
Revised 11/98 Index No. Plaintiff, - against - Defendant. Date of commencement of action Complete all item, marking ~mm, * *INAPPLICABLE" and "UM(NOWN, " if: appropriate)
Revised 11/98
Index No.
Plaintiff, - against -
Defendant. Date of commencement of action
Complete all item, marking ~ m m , * *INAPPLICABLE" and "UM(NOWN, " if: appropriate)
EXPERfiES: LYou may eled to list all aQenses an a weekly basis or all expawe8 on a moathly bnsis, however, you must be comsfstent. 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 fa0sl'chJ.y payment. Attach aB&tional sheet, if neeaed. Items included under "Othern should be listed separately w i t h separate dollar arnormts.)
-See listed 11 weekly 11 monthly
(a) fIOusing 2 . Rent 4. Candopliuiurn charges 2. mortgage and 5 . Cooperativa apartment
amortieation maintenance 3. Real estate taxes
f (b) Utilities 1. &el oil 2. Gas 3 . Electricity
$ Ic) Food 1. Groceries 3. SchQOl lunches 3 . Lunches at work 4. Dining Out
$ /d) Clothing 1. msband 2. sife
9 ( f ) Insurance 1. L t f % - 2. ~omeowner~s/tenaUt's 3. Pire, theft and
liability 4. Automotive 5. W r e l l a policy
4 . Telephone 5. water
'Total: Utilities
5. Liquor~alCohol 6 . Honte entertainment; 7. Other
3. Children 4. Other
Total : Clothing
3. Other
'Fatall Laundry
6. Medical plan 1. Dental plan 8. optical plan 9. Disability l a . workeE1s Eo@ensatioa L1. OthW
~otal: fnsurance 9
(g) Wreimbwsed medical 1. Medical 5. Surgical, nursing, 2. Dental hospital 3 . Optical 6. athex 4. Pharmaceutical
Total: Dnreimbursd medical
$ (h) mousehold maintenwace 1. Repairs 5. Painting - 2. Furniture, furnishings 6. ~anitation/caating
housewares 7. ~ardening/landscaping 3 . Cleaning supplies 8. snow removal 4. Amliances, including 9. ~xternination - -
maintenance lo. other
Total: Rousehold maintenance $
ti) musehold help 1. Babysitter 3. other a . Domestic (housekeeper, maid, e ta . )
Total: Household help -
( j ) Automotive yeax : Make : Personal: - Business: - Year: Make : personal: - Busineam - year t Make Personal: - Business: - 1. payments 4 . Car wash 2. G a s and o i l 5. Registration and licenae 3 . Repairs 6 . Farking a d tolls
7. other Total: A u t m t i v e
.$ (k) Educational 1. nursery end pre-school - 6. school transportation 2. Primary and secondary - 7 . school euppliesfbooks 3. College 8 . Tutoring 4. Post-graduate - 9. School events 5. Religious h t r u c t i o n - LO. Other
Total: Educational 9
(1) Recreational I. surmner camg 2. vacaticms 3 . Movies 4. Theatre, ba l le t , eke. 5. Video rentals 6. Tapes, a ' s , etc. 7. Cable t e l e v i s b n 8. Team Bports
S (m) Income taxes 1. Federal 2 , s t a t e
- 9 . country c1UbJpool o l d 1 0 . Sealth d u b 11. sporting goods - 12. BobbiB - 13. ~usic/dance lessons 14 , sports lessons 1s. Bkthday par t ies 16. Other
Total: Recreational
3 . c i t y 4. Social Security and
Medicare Tatal: Inrome taxee
$ (n) Miscellwews
I. Beauty parlodbarber 9 . W o n and ergani- 2 . Beauty aids/cosmetieEl, zation dues
drug items
3 . Cigweetesftobacoo 4 . Bwks, wgazinas,
aewepapers 5. Children's allowances 6 . G i f t s 7 . Charitable eonfributioriF- 8 . Religious organization
lo. Commutation an8 transportation
11. veterbazian/pet expenses 12. child support payments
(prior marriage) 13, Alimony and meintenance EMFents
(pr ior marriage) 14. Loan payioents 15. tlnreimbursea business
expenses ~ o t a l ! Miseellaaeous
to) Other 1. - 3 . 2 . 4,
Total: Other $
TDTm ZXW6B.S: $ 1-51. amm.: (skat;e s w c e of income and amv+al amaunt. Is*%a~b addik
tional sheet, i f neebed).
(a) S:alg.y or wages: (State whe,Zher iilcme has changed. d d n g the y&ar preceding b@s of this ~PfldavFt -, . If .so, set fbrth xihe and ad&*sS of all emgldyers during preceding Few and average . w ~ W y -4 W d . by
~ n & ~ ~ c e ,mert.ime earnin* sgpa;ratcily. Attrihh gYWi-dht& ~ye'aar's W-2, or i n e m tax return. l
(b) weekly de&ucti@ns : 1. Federal tax ................................ 9. New YOI& Stake tax. . ,. ... :. .................... 3. Local tax.. .................................... 4 , social C4eouriFy. ............ ... ........ .. .. ...................................... 5. Mediawe 6 . other payroll eductierw (epeoify) .........
(el social S d t g mtnber (dl Number an8 names of ,de~enden~s ola-Lmed: (el onus.', comrn i~ i~ , , fringe beneffik.s (uwe cf auto;
mea$e.ri;ifrigs, .etc . ) .............................. (f) PartnerehiQ, IQyaltfes, sale QZ wset.8
( h o m e aad inst&LBtek& paymmt,e). ....,...... :(g> ~ividen&. and iat,erest (s ta te Whether 'kaxable
ar not) ..................................... tb) Real estate (income &.Iy) ...................... (L:) ,huet,, az~EZt a w i n g and aflhUitise
.......... ('princ~gal d?dtribu.tioFi and income) ( j ) genaiim ( .3 .~cm only) ......................... (R) awr@s., pdm., g r e s 'leeate whether t d l e ) : (1) B.~@.&s., legacies eand .gifts; .................. (m) Indone f M m a l l other sourcea. ..................
(inelucIhg alimmy, matntenaace 01 child sQBPoR from g?-Lor tmrriage):
(n) T& pieferanae items: 1. && term capital gain rle&ietibn. .......... 2, . ,Depec$atib& amort iasttk~ or depletian. .... 3 . $took optiorts -- exceas o t f e ~ h market
-1- over amownt paFd., ..................... Q') If Sny &i$l.d o-r other .me&es of FQW ho@s€?boI@ ia employed, aet forth same sad cliat person'!? aahual income
(gl S E I C ~ $ ~ *:qu?&y;. .......:. : . ..........a,.. ' ..... (q) niaerbi~liGy benefit,^....... . . . . . . . . . . i . . . . . . . . . (r) Publip ~s&&gzloe. ........... ,. '. ................... (s') Other. ....................................... , .......
TOTAL % ~ k Q m :
IV . ~.SE!TP: (If %+uy assat is held j o h t l y with %p,ow ox mothar, '66 @tatel &st fartR yo& zesgee.ti~e #hazes. Attaab additipwl aB&$tS, if
b. T i t l e owner c . Type of a c c m t d. Source of futtds e. D a t e of deposit f . Amount $
Total: Other
Total: Cash Aaaountd 8 B. Securit ies
BOW, notas, mortgages 1.1 a , Description of senilrity
b. T i t l e hold& c. Location d. Date of acqwisition e. or iginal price ar value f. Source of funds to acguire g. current value $
Tofal: Sop&; notes, e ta .
Stocks, dp t~ ima cwnodity dontFaets 2 . 1 a. lXt4Criptio-n of secar i ty
b. 'Ti t le bolder c . &&tion a. Date of aqu i@i t ion e , origknal pdae d r value f . SourQe of funds to acquire 9 . current value $ -
2 . 2 a . Descsiptim of aecurity b. T i t l e held= c . rdocation d. Date of acquisitlan e . Original pr ice ox valtle f . Source of funds to acqui* g . Current value $
a . 3 a . ~ a s c r i g t i o n of security b. T i t l e holder
c . Location - d. Date of acquisition e . Originalpzice or w l u e f . Source of fun& t o acquire g . Current value $
Total: Stocks, options, etc. $
Bzoker margin accounts 3.1 a . Name and adeees of broker
b. T i t l e holder - - c. Date account 3pened d. Original w l u e of account e. Sourae of funds f . Current value $
Total: Margin account%
Total value of eecurities:
C. Loam to others and accounts receivable 1.1 a. Wtor'a name ant4 address
b. Original amount of loan ar debt c. Eorsrce of funds fr- wh*ch loern made or origb
of debt -
d. Date paymentts) due e. Current alDount due $.
d. Original pr ice e . Source of funds t o acquire E. AmDwt of c u r r a t l i en unpaid g. current f a i r marker value $
~ o t a l : Value of V d c l e s $
G. Real es t a t e (including r ea l property, leaseholds, Life es ta tea , e tc . a t market value -- do ncrt deduct any mortgage) 1.1 a . oeseriptioa
b. W e owner c. Date of acquisition d. Original price e. Sowce of funds t o ac-mire f . mount of mortgagg or l i e n unpaid
g. m i m a t e a current mizrket value 9
1.2 a . Description b. T i t l e owner c. Date of acquisition d. Original pr ice e , Souxce of fuads to acquire f , Mount of mortgage or l i e n urpaia
g . Estimated current mrh t v a h e $
1.3 a. Deecription h . T i t l e 0-E a. Date of abqnisitioa d. Or3ginal pdss e. BaEnce & M e t o auEpire f. ~ m m t of mortgage @r l i e n unpaid
g . Estimated w e n t market value 4 m t a l : Walue of real es t a t e
1.. 2 a. lA8oription b. Title owner c . Locatiari (i. Or%ginal price ot. value e , source af &kla to acquire f. mouht a$ l ien unpaid g. current value $
meal: ~ewelty, art, &C. :
1 . 2 a. Description b. Title owner c. L0cat iorr d. original price or value
e. Source of fund& to acwire f. Amount of lieu unpaid g. Curlrent value $
Total: Other
Tda\A4: WSETS $
Mort agar (8 orig 9 nal debt Date of inourring debt Monthly or other periodic payment Maturity date Amount of current debt $
Total: Mortgages payable
F. Taxes payable 1.1 a. D*scriptioa of tax
h. Amount of tax c. Dgte due
Total: Taxes payable $
G. Loans on life insurance policies 1.1 a. Name and address of insurer
b. Amount of loan a . Date incurred d. Purpose e. Name of borrewer f. Monthly or other periodic payment g. Amount of current debt $
Total: Life insurance loans $
H. Other liabilities 1.1 a. Degcription
b. Name and address of creditor E . Debtor d. Original amount of debt e. Date incurred f. Purpose g. Monthly or other periodic p a m n t h. Punwnt 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 s . Monthly or other miodic payment h. Amountof eurrent-debt $
Total: otkt Liabilities
TOTAL LIABILITIES: $
TOT& ASSETS:
TOTAL LI3LBZMTIZS:
NaT WORrn:
(minus)
. ASBETB W S P & R R I E D : ( L i s t a l l assets transferred in any manner during the preceding t h z e yaws, or lenqth of the marriage, whichevey is shorter I t r m f e r s i n the routine aourse 6f budlineas wfiLch rasultad in an exchange of asset8 of subs tan t i l ly equivgleat lralue need a& be specifically disclosed whwe such assets are othestrise identified in t k e statement of net woror13.
Description of Property
TO Whom Trmsferred and Relationghip to
Trawf exes Date of T r a d e r Value
VII. SXXPP@XT XEQUIBBMBNTB : (a) Deponent f s a t presreat (paying) (receiving) $ per (week) (month),
and priox to separation (peldl (received) $ p w (week1 (month1 t o cover expenses fox
lb) Deponent requests for support of each ohild $ per (week) (scpnth) Total for ohil&zgn $
Lcl Deponent ~-eqaeats for suppork of self 8 per iweek) (month1 . (dl B e day of the (week) (month) on whiah payment should be made i f f
w x r . co~mam m R E Q ~ ~ W : la) Dep@nent request8 for counsel fee and diebureente~lte the sum Of (b) Deponent han paid oouned the sun of $ and has agreed with
oounsel ooncerf%ing fees a9 follows:
(dl Deponent requires the gemices of an appraiser f w the following reasons:
X. Other dsta concerning the financial circumstances of the parkies that shoul& be bzou&t to the atteation of the Court are!
The foregoiug statements an8 a rider consisting of - pagels) annexed hereto and made part hereof, have been carefully read by tbe un8ersLgned who states that they are true and Qorreet.
Sworn to hefore me W s day of , 19
