COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : Index No. : : Plaintiff(s) -against- Calendar No. JUDICIAL SUBPOENA : Circuit Court for Case No. : City or County :Name Name Defendant(s) VS. : . . . . . . . . Street. Address . . . . . . . . . . . . . . . . . . . . . Apt..#. . . . . . . . . . . . .Street Address ... ..... .. Apt. # ( ) City State Zip Code Area Code ( ) Telephone City State Plaintiff THE PEOPLE OF THE STATE OF NEW YORK Zip Code Area Code Telephone Defendant FINANCIAL STATEMENT TO (Short) (DOM REL 30) I, GREETINGS: , state that: My name WE COMMAND YOU, that all businessor excuses being laid aside, you and each of you attend before I am the mother/ father and Check One (for example, aunt, grandfather, guardian, etc.) , the Honorable at the State Relationship Court of the minor child(ren): 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 Name Date of Birth Name Date of Birth Name Date of Birth Name Date of Birth Your failure to comply with this subpoenaDatepunishable as a contemptName is of Birth of court and will make you liable to Name Date of Birth 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 tofollowing is a list of my income and expenses (see below*): The comply. See definitions on back before filling out. Witness, Honorable Total monthly income (before taxes) Court in County, day of , 20 , one of the Justices of the $ Child support I am paying for my other child(ren) each month Alimony I am paying each month to Name of Person(s) Alimony I am receiving each month from (Attorney must sign above and type name below) Name of Person(s) For the child or children listed above: Monthly health insurance premium Work-related monthly child care expensesAttorney(s) for Extraordinary monthly medical expenses School and transportation expenses *To figure the monthly amount of expenses, weekly expenses should be multiplied by 4.3 and yearly expenses should be divided by 12. Office and P.O. Address If you do not pay the same amount each month for any of the categories listed, figure what your average monthly expense is. I solemnly affirm under the penalties of perjury that the contents of the foregoing paper are true to the best of my knowledge, information and belief.Telephone No.: Date Facsimile No.: E-Mail Address: Mobile Tel. No.: Signature American LegalNet, Inc. www.USCourtForms.com Page 1 of 2 DR 30 - Revised 8 Nov 2000 COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : Index No. : Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA : Total Monthly Income: Include income from all sources including self-employment, rent, royalties, : business income, salaries, wages, commissions, bonuses, dividends, pensions, interest, trusts, annuities, social security benefits, workers compensation, unemployment benefits, disability : benefits, alimony or maintenance received, tips, income from side jobs, severance pay, capitol gains, Defendant(s) : gifts, prizes, lottery winnings, etc. Do not report benefits from means-tested public assistance ...................................................... programs such as food stamps or AFDC. Extraordinary Medical Expenses: Uninsured expenses over $100 for a single illness or condition THE PEOPLE OF THE STATE OF NEWtreatment, asthma treatment, physical therapy, treatment for any including orthodontia, dental YORK TO chronic health problems, and professional counseling or psychiatric therapy for diagnosed mental disorders. Child Care Expenses: Actual child care expenses incurred on behalf of a child due to employment or job GREETINGS: search of either parent with amount to be determined by actual experience or the level required to provide quality care from a licensed source. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before the Honorable at Any Court School and Transportation Expenses: the expenses for attending a special or private elementary, at County of or secondary school tolocatedthe particular needs of the child or expenses for transportation of the meet in room child between the homes of the parents.20 , on the day of , , 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 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 penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com Page 2 of 2 DR 30 - Revised 8 Nov 2000