COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : IN THE DISTRICT COURT OF DOUGLASPlaintiff(s) KANSAS JUDICIAL SUBPOENA COUNTY, -against- : In the Matter of: ) : ) , ) Case No. DG : and ) Division 3 ) Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . ) . . . . . . . . . . . . . . . . . . . . ____________________________________) Pursuant to K.S.A. Chapter 60. THE PEOPLE OF THE STATE OF NEW YORK DOMESTIC RELATIONS AFFIDAVIT OF TO 1. Petitioner’s Residence______________________________________________________________ Petitioner’s ___________ GREETINGS: Date of Birth 2. 3. 4. 5. ______________________ Social Security Number ________________ Home Telephone Respondent’s Residence______________________________________________________________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court Respondent’s ____________ ______________________ _________________ locatedSocial Security Number at County of Date of Birth Home Telephone in room , on the day of , 20 , at o'clock in the noon, and at any recessed orDate of Marriage: _______________ as a witness in this action on the part of the adjourned date, to testify and give evidence Number of Marriages: _______________ Petitioner ______________ Respondent Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Number of children of marriage: ____________ the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. 6. Names, Social Security numbers, birth dates, and ages of minor children of the marriage: Witness, Honorable , one of the Justices of the Court in Name County, __________________ __________________ __________________ __________________ day of Social Security , 20 No. ___________________ ___________________ ___________________ ___________________ Date of Birth Age Custodian _____________ _____ _________ _____________ _____ _________ _____________ _____ _________ _____________ _____ (Attorney must sign above and type name below)_________ 7. Names, Social Security numbers, and ages of minor children of previous Attorney(s) for facts as to custody and support payments paid or received, if any. Support Name Social Sec. No. Age Custodian Payment __________________ _______________ ____ _________ $______ __________________ _______________ ____Office and P.O. Address _________ $______ __________________ _______________ ____ _________ $______ __________________ _______________ ____ _________ $______ marriage and Paid or Rec’d ________ ________ ________ ________ Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) 8. Calendar No. : JUDICIAL SUBPOENA Petitioner is employed by__________________________________________________________ -against: __________________________________________________________ Respondent is employed by__________________________________________________________ : __________________________________________________________ (Name and address of employer) : with monthly income as follows: A. Defendant(s) : . .Wage . Earner. . . . . . . . . . . . . . . . . . . . . Petitioner . . . . . . . . . .... ...... ........... 1. 2. 3. 4. Gross Income $____________ Other Income $____________ Subtotal Gross Income $____________ Federal Withholding: THE PEOPLE OF THE STATE OF NEW YORK (Claiming __ exemptions)$____________ 5. Federal Income Tax $____________ 6. OASDHI $____________ TO 7. Kansas Withholding $____________ 8. Subtotal Deductions $____________ 9. Net Income $____________ B. Respondent $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ GREETINGS: Self-Employed Petitioner Respondent Gross Income from selfemployment $____________ $___________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before 2. Other $____________ $___________ , the Honorable Income at the Court 3. Subtotal Gross Income $____________ $___________ located at County ofReasonable Business 4. on in room Expenses (itemizeday of , on the , 20 , at o'clock in the noon, and at any recessed attached exhibit) $____________ $___________ or adjourned date, to testify and give evidence as a witness in this action on the part of the 5. Self-Employment Tax $____________ $___________ 6. Estimated Tax Payments $____________ $___________ (Claim __ Exemptions) 7. Federal Income Tax $____________ $___________ 8. Kansas Withholding $___________ Your failure to comply with this $____________ subpoena is punishable as a contempt of court and will make you liable to 9. Subtotal Deductions $____________ $___________ the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a 10. Net Income result of your failure to minus Line (Line B.3 comply. B.9.) $____________ $___________ 1. Witness, Honorable Court in County, Pay period: ____________________day of Petitioner 9. , one of the Justices of the , 20 ______________________ Respondent The liquid assets of the parties are: A. B. C. D. Item Checking Accounts: _________________ _________________ Savings Accounts: _________________ _________________ Cash (Petitioner) (Respondent) Other _________________ _________________ (Attorney must sign above and type name below) Amount Joint or Individual (Specify) $______________ Attorney(s) for $______________ ____________________ ____________________ $______________ $______________ ____________________ ____________________ $______________and P.O. Address ____________________ Office $______________ ____________________ $______________ $______________ Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: 2 ____________________ ____________________ American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. 10. The monthly expenses of each party are: (Please indicate with an asterisk all figures : JUDICIAL SUBPOENA which are estimates rather than actual Plaintiff(s) taken from records.) figures -against- A. : Petitioner (Actual or : Estimated) Item Respondent (Actual or Estimated) : 1. Rent (if applicable)* $_______________ $_______________ 2. Food $_______________ $_______________ Defendant(s) : . .3. . . . . Utilities: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ........... Trash service $_______________ $_______________ Newspaper $_______________ $_______________ Telephone $_______________ $_______________ Gas $_______________ $_______________ THE PEOPLE OF THE STATE OF NEW YORK $_______________ Water $_______________ Lights $_______________ $_______________ Other $_______________ $_______________ TO 4. Insurance: Life $_______________ $_______________ Health $_______________ $_______________ Car $_______________ $_______________ House/Rental $_______________ $_______________ GREETINGS: Other $_______________ $_______________ 5. Medical and dental $_______________ $_______________ 6. Prescription YOU, $_______________ WE COMMANDdrugs that all business$_______________ aside, you and each of you attend before and excuses being laid 7. Child $_______________ $_______________ , the Honorable care (work related) at the Court 8. Child care (non-work related) $_______________ $_______________ located at County ofClothing 9. $_______________ $_______________ $_______________ $_______________ recessed in10. room School ,expenses day of on the , 20 , at o'clock in the noon, and at any Hair cuts and beauty $_______________ or11. adjourned date, to testify and give evidence as a$_______________ on the part of the witness in this action 12. Car repair $_______________ $_______________ 13. Gas and oil $_______________ $_______________ 14. Personal property tax $_______________ $_______________ 15. Miscellaneous (Specify) _______________________ $_______________ Your failure to comply with this subpoena is punishable as a contempt of $_______________ liable to court and will make you _______________________ $_______________ $_______________ the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a _______________________ $_______________ $_______________ result of your failure to comply. 16. Debt Payments (Specify) _______________________ $_______________ $_______________ _______________________ $_______________ $_______________ Witness, Honorable , one of the Justices of the _______________________ $_______________ $_______________ Court in County, Total day of , 20 $_______________ $_______________ *Show house payments, mortgage payments, etc. in Section 10.B (Attorney must sign above and type name below) B. Monthly payments to banks, loan companies or on credit accounts: (Indicate actual or estimate, use asterisk for secured.) DO NOT LIST ANY PAYMENTS INCLUDED IN PART 10.A. ABOVE. Amount of Attorney(s) for Payment/ When Date of Responsibility Creditor Incurred Last Payment Balance Petitioner Respondent _________ ________ _____________ $________ $___________ $___________ _________ ________ _____________ $________ $___________ $___________ _________ ________ _____________ $________ $___________ $___________ Office and $___________ P.O. Address _________ ________ _____________ $________ $___________ _________ ________ _____________ $________ $___________ $___________ _________ ________ _____________ $________ $___________ $___________ Subtotal of Payments $___________ $___________ Telephone $___________ No.: Total $___________ Facsimile No.: E-Mail Address: Mobile Tel. No.: 3 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : C. Total Living Expenses : -against1. 2. 3. 4. Total funds available to Petitioner and Respondent (from No. 8) Total needed (from No. 10, A. and B.) Net balance Projected child support JUDICIAL SUBPOENA : Plaintiff(s) Calendar No. Petitioner (Actual or Estimated) Respondent (Actual or Estimated) $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ : : Defendant(s) : . . . . . .Payments. .or . .contributions. . received, . . . . . paid, for support of others. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or . . . . D. source and amount. Source ______________________ (+/-) ______________________ (+/-) THE PEOPLE OF THE STATE OF NEW YORK ______________________ (+/-) ______________________ (+/-) Petitioner $_______________ $_______________ $_______________ $_______________ Specify Respondent $_______________ $_______________ $_______________ $_______________ TO 11. How much does the party who provides health care pay for family coverage? $___________________ per _____. How much does it cost the provider to furnish health insurance only on the GREETINGS: provider? $___________________ per _____. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of THE FOLLOWING INFORMATION IF APPLICABLE. FURNISH in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the 12. Income and financial resources of children. Income/Resources Amount _____________________________ $______________ _____________________________ $______________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to _____________________________ the party on whose behalf this subpoena was issued for a maximum $______________ all damages sustained as a penalty of $50 and _____________________________ $______________ result of your failure to comply. 13. Child support adjustments requested. Witness, Honorable Court in 14. day of , Long County, Distance Visitation Costs 20 Visitation Adjustment Income Tax Consideration Special Needs Agreement Past Minority Overall Financial Condition Petitioner Respondent , one of the Justices of the $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ (Attorney must sign above and type name below) $_____________ $_____________ All other personal property including retirement benefits (including but not Attorney(s) for limited to qualified plans such as profit-sharing, pension, IRA, 401(k), or other savings-type employee benefits, nonqualified plans, and deferred income plans), and ownership thereof (joint or individual), including policies of insurance, identified as to nature or description, ownership (joint or individual), and actual or estimated value. Joint Office and P.O. Address or Individual Amount (Specify) __________________________ $____________ _________________ __________________________ $____________ _________________ Telephone __________________________ $____________ No.: _________________ __________________________ $____________ Facsimile No.: _________________ E-Mail Address: Mobile Tel. No.: 4 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : THE FOLLOWING NEED NOT Plaintiff(s) BE FURNISHED IN POST JUDICIAL SUBPOENA JUDGMENT PROCEDURES. -against- : 15. List real property identified as to description, ownership (joint or individual) : and actual or estimated value. : Property Description Ownership Actual/Estimated Value _____________________________________________________________________________________ _____________________________________________________________________________________ Defendant(s) : ...................................................... _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ THE PEOPLE OF THE STATE OF NEW YORK TO 16. Identify the property if any acquired by each of the parties prior to marriage or acquired during marriage by a will or inheritance. Property Description GREETINGS: Source of Ownership Ownership Actual/ Estimated Value _____________________________________________________________________________________ _____________________________________________________________________________________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before _____________________________________________________________________________________ , the Honorable at the Court _____________________________________________________________________________________ located at County of _____________________________________________________________________________________ _____________________________________________________________________________________ in room , on the day of , 20 , at o'clock in the noon, and at any recessed _____________________________________________________________________________________ or adjourned date, to testify and give evidence as a witness in this action on the part of the 17. List debt obligations, including maintenance, not listed in Section 10.A. or 10.B. above, identified with this subpoena is names, of a contempt or court and will and obligees, Your failure to comply as to name or punishable as obligor of obligors make you liable to balance due and rate subpoena was issued for maximum secured, identify the sustained as the party on whose behalf this at which payable; aand, if penalty of $50 and all damages encumbereda property. result of your failure to comply. Debt Obligation Obligor Witness, Honorable Obligee Balance Due Payment Encumbered Property , oneRate Justices of the of the Court in County, day of , 20 _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ (Attorney must sign above and type name below) _____________________________________________________________________________________ Attorney(s) for 18. List health insurance coverage and the right, pursuant to ERISA Sec. 601-608, 29 U.S.C. Sec. 1161-1168 (1986), to continued coverage by the spouse who is not a member of the covered employee group. Health Insurance COBRA Continuation Office and P.O. Address No Yes ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ _____ _____ _____ Telephone No.: _____ Facsimile_____ No.: _____ _____ _____ _____ _____ Unknown _____ _____ _____ _____ _____ E-Mail Address: Mobile Tel. No.: 5 American LegalNet, Inc. www.USCourtForms.com