SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NASSAU
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MARY JONES,
Plaintiff,
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IndexNo. 2345/03
DEMAND FOR NET
WORTH STATEMENT
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JOHN JONES,
Defendant.
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SIR:
PLEASE TAKE NOTICE that the plaintiff demands that you serve upon the undersigned, within
twenty (20) days from the date hereof, a sworn statement of the defendant's net worth, which shall
include all income and assets of whatever kind and nature wherever situated and shall include a list
of all assets transferred in any manner during the preceding three (3) years, together with a current
and representative pay-check stub and the most recently filed state and federal income tax returns
and a copy of your attorney’s retainer agreement, pursuant to Domestic Relations Law Section 236
and in the form prescribed by the New York Rules of Court Section 202.l6(b). Non-compliance
shall be punishable by any or all of the penalties prescribed in Section 3l26 of the Civil Practice Law
and Rules.
Dated: Garden City, New York
_____________, 20___
TO:
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George G. Adversary, Esq.
890 Smith Place
Garden City, New York 11530
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Yours, etc.
DaSilva, Hilowitz & McEvily LLP
Attorneys for Plaintiff
Office and P.O. Address
585 Stewart Avenue
Garden City, New York 11530
Tel. (516) 222-0700
SUPREME COURT
COUNTY OF ___________________
Index No.
----------------------------------------------------------Plaintiff,
STATEMENT OF
NET WORTH
(DRL Section 236)
-againstDefendant.
----------------------------------------------------------STATE OF NEW YORK
ss.:
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COUNTY OF ______________
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Date of commencement of action ____________
Complete all items, marking “NONE,” “INAPPLICABLE” AND “UNKNOWN” (if appropriate)
________________, the (Petitioner) (Respondent) (Plaintiff) (Defendant) herein, being duly sworn, deposes and says
that the following is an accurate statement as of ________________, of my net worth (assets of whatsoever kind and
nature and wherever situated minus liabilities), statement of income from all sources and statement of assets transferred
of whatsoever kind and nature and wherever situated:
I.
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
(j)
(k)
(l)
(m)
(n)
(o)
(p)
(q)
(r)
(s)
FAMILY DATA
Husband’s age ______________________
Wife’s age ______________________
Date married ______________________
Date (separated) (divorced) ______________________
Number of dependent children under 21 years _____________
Names and ages of children
______________________
______________________
______________________
Custody of Children [ ] Husband
[ ] Wife
Minor children of prior marriage [ ] Husband
[ ] Wife
(Husband) (Wife) (paying) (receiving) $________ as alimony (maintenance) and/or $________ child support in
connection with prior marriage
Custody of children of prior marriage
Name ____________________________________________
Address __________________________________________
Is marital residence occupied by [ ] Husband
[ ] Wife
[ ] Both
Husband’s present address
___________________________________________________
Wife’s present address
___________________________________________________
Occupation of Husband ________________________ Occupation of Wife _____________________
Husband’s employer _________________________________
Wife’s employer ____________________________________
Education, training and skills [include dates of attainment of degrees, etc.]
Husband _______________________________________________________________________
Wife __________________________________________________________________________
Husband’s health __________________
Wife’s health _____________________
Children’s health __________________
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I.a.
HEALTH COVERAGE INFORMATION
HUSBAND’S PLAN
WIFE’S PLAN
Group Health Plan #1 Name:
Address for Plan #1:
Identification number – Plan #1
Plan administrator – Plan #1
Type of coverage – Plan #1
HUSBAND’S PLAN
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Group Health Plan #2 Name:
Address for Plan #2:
Identification number – Plan #2
Plan administrator – Plan #2
Type of coverage – Plan #2
1b.
ALTERNATE RECIPIENTS OF HEALTH COVERAGE
NAMES OF CHILDREN
1
DATE OF
BIRTH
3
4
5
6
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WIFE’S PLAN
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OTHER INFORMATION
Street address (mailing if different)
City, State, Zip (mailing if different)
Home telephone number
Driver’s license number and State
Employer’s name
Employer’s street address
Employer’s City, State, Zip
Employer’s telephone number
SOCIAL
SECURITY #
ADDRESS
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HUSBAND
WIFE
II.
EXPENSES:
(You may elect to list all expenses on a weekly basis or all expenses on a monthly basis;
however, you must be consistent. If any items are paid on a monthly basis, divide by 4.3 to
obtain weekly payments; if any items are paid on a weekly basis, multiply by 4.3 to obtain
monthly payment. Attach additional sheet, if needed. Items included under “Other” should be
listed separately with separate dollar amounts.)
Expenses listed
(a)
1.
2.
3.
Housing
Rent
Mortgage and amortization
Real estate taxes
[
] weekly
______
______
______
[
] monthly
4.
5.
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Condominium charges
Cooperative apartment
maintenance
______
______
Total: Housing
(b)
1.
2.
3.
(c)
1.
2.
3.
4.
(d)
1.
2.
(e)
1.
2.
Utilities
Fuel oil
Gas
Electricity
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______
______
______
Food
Groceries
School lunches
Lunches at work
Dining out
Clothing
Husband
Wife
______
______
______
______
______
______
Laundry
Laundry at home
Dry cleaning
______
______
4.
5.
5.
6.
7.
3.
4.
Telephone
Water
______
______
Total: Utilities
Liquor/alcohol
Home entertainment
Other
$______
______
______
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3.
(g)
1.
2.
3.
(h)
1.
2.
3.
4.
Insurance
Life
Homeowner’s/tenant’s
Fire, theft and liability
Automotive
Umbrella policy
Medical plan
______
______
______
______
______
______
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Unreimbursed medical
Medical
Dental
Optical
Household maintenance
Repairs
Furniture, furnishings,
housewares
Cleaning supplies
Appliances, including
maintenance
______
______
______
______
______
______
7.
8.
9.
10.
11.
Dental plan
Optical plan
Disability
Workers’ Compensation
Other_____
5.
6.
7.
8.
9.
10.
Pharmaceutical
______
Surgical, nursing, hospital ______
Other ____________
______
Total: Unreimbursed Medical
Painting
Sanitation/carting
Gardening/landscaping
Snow removal
Extermination
Other_________
$______
______
______
______
______
______
Total: Insurance
4.
5.
6.
$______
Other ________
Total: Laundry
(f)
1.
2.
3.
4.
5.
6.
$______
______
______
______
Total: Food
Children
Other: _______
Total: Clothing
$______
______
______
______
______
______
______
$______
$______
Total: Household Maintenance $______
(i)
1.
2.
Household help
Babysitter
Domestic
(housekeeper, maid, etc.)
______
3.
Other _____
______
______
Total: Household Help
(j)
Automotive
Year ____________ Make ________________________
Year ____________ Make ________________________
Year ____________ Make :________________________
1.
2.
3.
4.
Payments
Gas and oil
Repairs
Car wash
______
______
______
______
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(k)
1.
2.
3.
4.
5.
Educational
Nursery and pre-school
Primary and secondary
College
Post-graduate
Religious instruction
(l)
1.
2.
3.
4.
5.
6.
7.
8.
Recreational
Summer camp
Vacations
Movies
Theater, ballet, etc.
Video rentals
Tapes, CDs, etc.
Cable television
Team sports
(m)
1.
2.
Income taxes
Federal
State
(n)
1.
2.
5.
6.
7.
8.
Miscellaneous
Beauty parlor/barber
Beauty aids/cosmetics,
drug items
Cigarettes/tobacco
Books, magazines,
newspapers
Children’s allowances
Gifts
Charitable contributions
Religious organization dues
(o)
1.
Other
________________
3.
4.
5.
6.
7.
______
______
______
______
______
______
______
______
______
______
______
______
______
______
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______
______
______
______
______
______
______
______
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6.
7.
8.
9.
10
9.
10.
11.
12.
13.
14.
15.
16.
Personal [
]
Business [
]
Personal [
]
Business [
]
Personal [
]
Business [
]
Registration and license
Parking and tolls
Other _____________
______
______
______
Total: Automotive
School transportation
School supplies/books
Tutoring
School events
Other _____
Total: Educational
9.
10.
11.
12.
13.
14.
15.
3.
$______
______
______
______
______
______
$______
Country club/pool club
______
Health club
______
Sporting goods
______
Hobbies
______
Music/dance lessons
______
Sports lessons
______
Birthday parties
______
Other: ______
______
Total: Recreational
$______
City
______
Social Security and
Medicare
______
Total: Income Taxes
$______
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3.
4.
$______
Union/organization dues ______
Commutation/transportation
______
Veterinarian/pet expenses ______
Child support payments
(prior marriage)
______
Alimony and maintenance
payments (prior marriage) ______
Loan payments
______
Unreimbursed business
expenses
______
Total: Miscellaneous
$______
________________
______
2.
________________
______
4.
________________
Total: Other
______
TOTAL EXPENSES
III.
A.
$______
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, 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 .........................................................................................
_____
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$______
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TOTAL INCOME
$______
ASSETS: (If any asset is held jointly with spouse or another, so state, and set forth your respective shares. Attach
additional sheets, if needed.)
Cash Accounts
Cash
1.1 a. Location __________________________________
b. ____________________________Source of funds
c. __________________________________ Amount
$_____
Total: Cash
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$______
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.
b.
c.
d.
e.
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Financial institution __________________________
Account number_____________________________
Title holder ________________________________
Date opened _______________________________
Source of funds _____________________________
Balance ___________________________________
Total: Checking
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$_____
$_____
$______
Saving accounts (including individual, joint, Totten trust
certificates of deposit, treasury notes)
3.1 a.
b.
c.
d.
e.
f.
g.
Financial institution __________________________
Account number_____________________________
Title holder ________________________________
Type of account ____________________________
Date opened _______________________________
Source of funds _____________________________
Balance ___________________________________
3.2 a.
b.
c.
d.
e.
f.
g.
Financial institution _________________________
Account number ____________________________
Title holder ________________________________
Type of account ____________________________
Date opened _______________________________
Source of funds _____________________________
Balance ___________________________________
Total: Savings
$______
Security deposits, earnest money, etc.
4.1 a.
b.
c.
d.
e.
f.
Other
5.1 a.
b.
c.
d.
e.
f.
$_____
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$_____
Location __________________________________
Title owner ________________________________
Type of deposit _____________________________
Source of funds _____________________________
Date of deposit _____________________________
Amount ___________________________________
$_____
Total: Security Deposits, etc.
$______
Location __________________________________
Title owner ________________________________
Type of account ____________________________
Source of funds _____________________________
Date of deposit _____________________________
Amount ___________________________________
Total: Other
Total: Cash Accounts
$______
$______
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$_____
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 ______________________________
$_____
Total: Bonds, Notes, etc.
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Stocks, options and commodity contracts
2.1 a. Description of security _______________________
b. Title holder ________________________________
c. Location __________________________________
d. Date of acquisition __________________________
e. Original price or value _______________________
f. Source of funds to acquire ____________________
g. Current value ______________________________
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$_____
2.2 a.
b.
c.
d.
e.
f.
g.
Description of security _______________________
Title holder ________________________________
Location __________________________________
Date of acquisition __________________________
Original price or value _______________________
Source of funds to acquire ____________________
Current value ______________________________
2.3 a.
b.
c.
d.
e.
f.
g.
Description of security _______________________
Title holder ________________________________
Location __________________________________
Date of acquisition __________________________
Original price or value _______________________
Source of funds to acquire ____________________
Current value ______________________________
$_____
Total: Stocks, Options, etc.
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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 Account
$______
$_____
Total: Value of Securities
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.
b.
c.
D.
E.
F.
Debtor’s name and address ____________________
Original amount of loan or debt ________________
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
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
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
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 paid ___________________
g. Current fair market value _____________________
$_____
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1.2 a.
b.
c.
d.
e.
f.
g.
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$______
$______
$______
Description ________________________________
Title owner ________________________________
Date of acquisition __________________________
Original price ______________________________
Source of funds to acquire ____________________
Amount of current lien unpaid _________________
Current fair market value _____________________
$_____
Total: Value of Vehicles
$______
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.
g.
1.2 a.
b.
c.
d.
e.
f.
g.
1.3 a.
b.
c.
d.
e.
f.
g.
H.
J.
$_____
Description ________________________________
Title owner ________________________________
Date of acquisition __________________________
Original price ______________________________
Source of funds to acquire ____________________
Amount of mortgage or lien unpaid _____________
Estimated current market value ________________
$_____
Description ________________________________
Title owner ________________________________
Date of acquisition __________________________
Original price ______________________________
Source of funds to acquire ____________________
Amount of mortgage or lien unpaid _____________
Estimated current market value ________________
$______
Total: Value of Real Estate
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$______
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.
b.
c.
d.
e.
f.
g.
h.
I.
Amount of mortgage or lien unpaid _____________
Estimated current market value ________________
Description of trust __________________________
Location of assets ___________________________
Title owner ________________________________
Date of acquisition __________________________
Original investment _________________________
Source of funds _____________________________
Amount of unpaid liens _______________________
Current value ______________________________
$_____
Total: Vested Interest in Trusts
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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
Household furnishings
1.1 a. Description ________________________________
b. Location __________________________________
c. Title owner ________________________________
d. Original price ______________________________
e. Source of funds to acquire ____________________
$______
$______
f.
g.
Amount of lien unpaid _______________________
Current value ______________________________
$_____
Total: Household Furnishings
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$______
K.
L.
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.
$______
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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.
b.
c.
d.
e.
f.
g.
Description ________________________________
Title owner ________________________________
Location __________________________________
Original price or value _______________________
Source of funds to acquire ____________________
Amount of lien unpaid _______________________
Current value ______________________________
Total: Other
$_____
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$_____
TOTAL ASSETS
V.
A.
LIABILITIES
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.
b.
c.
d.
e.
f.
g.
Name and address of creditor __________________
Debtor ____________________________________
Amount of original debt ______________________
Date of incurring debt ________________________
Purpose ___________________________________
Monthly or other periodic payment _____________
Amount of current debt _______________________
$_____
$_____
$______
$______
1.3 a.
b.
c.
d.
e.
f.
g.
Name and address of creditor __________________
Debtor ____________________________________
Amount of original debt ______________________
Date of incurring debt ________________________
Purpose ___________________________________
Monthly or other periodic payment _____________
Amount of current debt _______________________
$_____
1.4 a.
b.
c.
d.
e.
f.
g.
Name and address of creditor __________________
Debtor ____________________________________
Amount of original debt ______________________
Date of incurring debt ________________________
Purpose ___________________________________
Monthly or other periodic payment _____________
Amount of current debt _______________________
$_____
1.5 a.
b.
c.
d.
e.
f.
g.
Name and address of creditor __________________
Debtor ____________________________________
Amount of original debt ______________________
Date of incurring debt ________________________
Purpose ___________________________________
Monthly or other periodic payment _____________
Amount of current debt _______________________
$_____
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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.
b.
c.
d.
e.
f.
g.
C.
$______
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$_____
Name and address of note holder _______________
Debtor ____________________________________
Amount of original debt ______________________
Date of incurring debt ________________________
Purpose ___________________________________
Monthly or other periodic payment _____________
Amount of current debt _______________________
$_____
Total: Accounts Payable
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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.
b.
c.
d.
e.
f.
g.
D.
Name and address of creditor __________________
Debtor ____________________________________
Amount of original debt ______________________
Date of incurring debt ________________________
Purpose ___________________________________
Monthly or other periodic payment _____________
Amount of current debt _______________________
$_____
Total: Installment Accounts
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Brokers’ margin accounts
1.1 a. Name and address of broker ___________________
b. Amount of original debt ______________________
c. Date of incurring debt ________________________
d. Purpose ___________________________________
e. Monthly or other periodic payment _____________
f. Amount of current debt _______________________
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$_____
Total: Broker’s Margin Account
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.
b.
c.
d.
e.
f.
g.
h.
F.
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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: Taxes Payable
G.
$______
$_____
Name and address of mortgagee ________________
Address of property mortgaged ________________
Mortgagor(s) _______________________________
Original debt _______________________________
Date of incurring debt ________________________
Monthly or other periodic payment _____________
Maturity date _______________________________
Amount of current debt _______________________
$_____
Total: Mortgages Payable
Taxes payable
1.1 a. Description of tax ___________________________
b. Amount of tax ______________________________
c. Date due __________________________________
$______
$______
$_____
Total: Life Insurance Loans
$______
H.
Other liabilities
1.1 a. Description ________________________________
b. Name and address of creditor __________________
c. Debtor ____________________________________
d. Original amount of debt ______________________
e. Date incurred ______________________________
f. Purpose ___________________________________
g. Monthly or other periodic payment _____________
h. Amount of current debt _______________________
1.2 a.
b.
c.
d.
e.
f.
g.
h.
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$_____
Description ________________________________
Name and address of creditor __________________
Debtor ____________________________________
Original amount of debt ______________________
Date incurred ______________________________
Purpose ___________________________________
Monthly or other periodic payment _____________
Amount of current debt _______________________
Total: Other liabilities
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$____
$______
TOTAL LIABILITIES
$______
NET WORTH
TOTAL ASSETS:
TOTAL LIABILITIES:
NET WORTH:
VI.
(minus)
($____________)
$____________
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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])
Description
of Property
VII.
$____________
To Whom Transferred
and Relationship to Transferee
Date of
Transfer
Value
____________________
________________________________
____________
_________
____________________
________________________________
____________
_________
____________________
________________________________
____________
_________
____________________
________________________________
____________
_________
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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
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)
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There is (not) a retainer agreement or written agreement relating to payment of legal fees. (A copy of any
such agreement must be annexed.)
ACCOUNTANT AND APPRAISAL FEES REQUIREMENTS
(a)
(b)
(c)
(d)
X.
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(a)
Deponents request for accountants’ fees and disbursements the sum of $________ (include basis for fee,
e.g., hourly rate, flat rate)
Deponent requests for appraisal fees and disbursements the sum of $________ (include basis for fee, e.g.,
hourly rate, flat rate)
Deponent
requires
the
services
of
an
accountant
for
the
following
reasons:
__________________________
____________________________________________________________________________________
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Deponent requires the services of an appraiser for the following reasons: __________________________
____________________________________________________________________________________
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.
Sworn to before me this ________
day of ________, 20___
__________________________________________
(Petitioner)
(Respondent)
(Plaintiff) (Defendant)
s/ _______________________________
Attorney’s Name
Attorney’s Address and Telphone Number
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