FAMILY PART CASE INFORMATION STATEMENT This form and attachments are confidential pursuant to Rules 1:38-3(d)(1) and 5:5-2(f) Attorney(s): Office Address Tel. No./Fax No. Attorney(s) for: SUPERIOR COURT OF NEW JERSEY CHANCERY DIVISION, FAMILY PART COUNTY Plaintiff, vs. DOCKET NO. CASE INFORMATION STATEMENT OF Defendant. NOTICE: This statement must be fully completed, filed and served, with all required attachments, in accordance with Court Rule 5:5-2 based upon the information available. In those cases where the Case Information Statement is required, it shall be filed within 20 days after the filing of the Answer or Appearance. Failure to file a Case Information Statement may result in the dismissal of a party’s pleadings. PART A - CASE INFORMATION: Date of Statement Date of Divorce (post-Judgment matters) Date(s) of Prior Statement(s) Your Birthdate Birthdate of Other Party Date of Marriage Date of Separation Date of Complaint Does an agreement exist between parties relative to any issue? summary (if oral). ISSUES IN DISPUTE: Cause of Action Custody Parenting Time Alimony Child Support Equitable Distribution Counsel Fees Other issues [be specific] Yes No. If Yes, ATTACH a copy (if written) or a 1. Name and Addresses of Parties: Your Name _____________________________________________________________________________________________ Street Address _________________________________________________ City_________________ State/Zip_________ Other Party’s Name _______________________________________________________________________________________ Street Address _________________________________________________ City_________________ State/Zip_________ 2. Name, Address, Birthdate and Person with whom children reside: a. Child(ren) From This Relationship Child’s Full Name Address Birthdate Person’s Name b. Child(ren) From Other Relationships Child’s Full Name Address Birthdate Person’s Name Effective 09/01/2009, CN 10482-English page 1 American LegalNet, Inc. www.FormsWorkFlow.com PART B - - MISCELLANEOUS INFORMATION: 1. Information about Employment (Provide Name & Address of Business, if Self-employed) Name of Employer/Business ___________________________ Address ___________________________________________ __________________________________________________ Name of Employer/Business ___________________________ Address ___________________________________________ __________________________________________________ Yes No. Type of Insurance: 2. Do you have Insurance obtained through Employment/Business? Medical Yes No; Dental Yes No; Prescription Drug Yes No; Life Yes No; Disability Yes No Other (explain) _________________________________________________________________________________________ Is Insurance available through Employment/Business? Yes No Explain:_________________________________ ________________________________________________________________________________________________________ 3. ATTACH affidavit of Insurance Coverage as required by Court Rule 5:4-2 (f) (See Part G) 4. Additional Identification: Confidential Litigant Information Sheet: Filed 5. Yes No ATTACH a list of all prior/pending family actions involving support, custody or Domestic Violence, with the Docket Number, County, State and the disposition reached. Attach copies of all existing Orders in effect. PART C. - INCOME INFORMATION: Complete this section for self and (if known) for spouse. 1. LAST YEAR’S INCOME Yours Spouse or Former Spouse Joint 1. Gross earned income last calendar (year) 2. 3. Unearned income (same year) $ Total Income Taxes paid on income (Fed., State, F.I.C.A., and $ S.U.I.). If Joint Return, use middle column. $ $ $ $ Net income (1 + 2 - 3) $ $ 4. $ $ ATTACH to this form a corporate benefits statement as well as a statement of all fringe benefits of employment. (See Part G) ATTACH a full and complete copy of last year’s Federal and State Income Tax Returns. ATTACH W-2 statements, 1099’s, Schedule C’s, etc., to show total income plus a copy of the most recently filed Tax Returns. (See Part G) State Tax Return W-2 Other Check if attached: Federal Tax Return 2. PRESENT EARNED INCOME AND EXPENSES Other Party (if known) Yours 1. Average gross weekly income (based on last 3 pay periods – ATTACH pay stubs) Commissions and bonuses, etc., are: included not included* not paid to you. $ $ *ATTACH details of basis thereof, including, but not limited to, percentage overrides, timing of payments, etc. ATTACH copies of last three statements of such bonuses, commissions, etc. 2. Deductions per week (check all types of withholdings): Federal State F.I.C.A Other $ $ 3. Net average weekly income (1 - 2) $ $ 3. YOUR CURRENT YEAR-TO-DATE EARNED INCOME 1. 2. GROSS EARNED INCOME: $ TAX DEDUCTIONS: (Number of Dependents: a. Federal Income Taxes b. N.J. Income Taxes c. Other State Income Taxes d. FICA Provide Dates: From: Number of Weeks To: ) a. b. c. d. $ $ $ $ Effective 09/01/2009, CN 10482-English page 2 American LegalNet, Inc. www.FormsWorkFlow.com e. Medicare f. S.U.I. / S.D.I. g. Estimated tax payments in excess of withholding h. i. e. f. g. h. i. TOTAL 3. GROSS INCOME NET OF TAXES $ 4. OTHER DEDUCTIONS a. Hospitalization/Medical Insurance b. Life Insurance c. Union Dues d. 401(k) Plans e. Pension/Retirement Plans f. Other Plans - specify g. Charity h. Wage Execution i. Medical Reimbursement (flex fund) j. Other $ $ If mandatory, check box a. b. c. d. e f. g. h. i. j. TOTAL 5. $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ NET YEAR-TO-DATE EARNED INCOME: $ NET AVERAGE EARNED INCOME PER MONTH: $ NET AVERAGE EARNED INCOME PER WEEK $ 5. YOUR YEAR-TO-DATE GROSS UNEARNED INCOME FROM ALL SOURCES [including, but not limited to, income from unemployment, disability and/or social security payments, interest, dividends, rental income and any other miscellaneous unearned income] Source How often paid Year to date amount $ $ $ $ $ $ $ $ $ TOTAL GROSS UNEARNED INCOME YEAR TO DATE $ Effective 09/01/2009, CN 10482-English page 3 American LegalNet, Inc. www.FormsWorkFlow.com 5. ADDITIONAL INFORMATION: 1. How often are you paid? 2. What is your annual salary? $ 3. Have you received any raises in the current year? 4. Do you receive bonuses, commissions, or other compensation, including distributions, taxable or non-taxable, in addition to your regular salary? Yes No. If yes, explain. 5. Did you receive bonuses, commissions, or other compensation, including distributions, taxable or non-taxable, in addition to your regular salary during the current or immediate past calendar year? Yes No. If yes, explain and state the date(s) of receipt and set forth the gross and net amounts received. 6. Do you receive cash or distributions not otherwise listed? 7. Have you received income from overtime work during either the current or immediate past calendar year? If yes, explain. 8. Have you been awarded or granted stock options, restricted stock or any other non-cash compensation or entitlement during the Yes No. If yes, explain. current or immediate past calendar year? 9. Have you received any other supplemental compensation during either the current or immediate past calendar year? Yes No. If yes, state the date(s) of receipt and set forth the gross and net amounts received. Also describe the nature of any supplemental compensation received. Yes No. If yes, provide the date and the gross/net amount. Yes No. If yes, explain. Yes No. 10. Have you received income from unemployment, disability and/or social security during either the current or immediate past calendar Yes No. If yes, state the date(s) of receipt and set forth the gross and net amounts received. year? 11. List the names of the dependents you claim. 12. Are you paying or receiving any alimony? Yes No. If yes, how much and to whom paid or from who received? 13. Are you paying or receiving any child support? Yes each child and to whom paid or from whom received. 14. Is there a wage execution in connection with support? No. If yes, list names of the children, the amount paid or received for Yes No. If yes explain. 15. Has a dependent child of yours received income from social security, SSI or other government program during either the current or Yes No. If yes, explain the basis and state the date(s) of receipt and set forth the gross and net immediate past calendar year? amounts received. 16. Explanation of Income or Other Information: Effective 09/01/2009, CN 10482-English page 4 American LegalNet, Inc. www.FormsWorkFlow.com PART D - - MONTHLY EXPENSES (computed at 4.3 wks/mo.) Joint Marital Life Style should reflect standard of living established during marriage. Current expenses should reflect the current life style. Do not repeat those income deductions listed in Part C - 3. Joint Marital Life Style Current Life Style Family, including Yours and _____ children _____ children SCHEDULE A: SHELTER If Tenant $ $ Rent............................................................................................... $ $ Heat (if not furnished)................................................................... $ $ Electric & Gas (if not furnished)................................................... $ $ Renter’s Insurance ........................................................................ $ $ Parking (at Apartment) ................................................................. $ $ Other charges (Itemize)................................................................. $ $ If Homeowner $ $ Mortgage $ $ Real Estate Taxes (if not included w/mortgage payment)............. $ $ Homeowners Ins (if not included w/mortgage payment) ............. $ $ Other Mortgages or Home Equity Loans ...................................... $ $ Heat (unless Electric or Gas) ........................................................ $ $ Electric & Gas............................................................................... $ $ Water & Sewer ............................................................................. $ $ Garbage Removal ......................................................................... $ $ Snow Removal.............................................................................. $ $ Lawn Care..................................................................................... $ $ Maintenance.................................................................................. $ $ Repairs .......................................................................................... $ $ Other Charges (Itemize)................................................................ $ $ $ Tenant or Homeowner: Telephone ..................................................................................... $ $ $ Mobile/Cellular Telephone ........................................................... $ $ Service Contracts on Equipment................................................... $ $ Cable TV....................................................................................... Plumber/Electrician ...................................................................... Equipment & Furnishings ............................................................. Internet Charges............................................................................ $ $ $ $ $ Other (itemize).............................................................................. $ $ $ $ TOTAL SCHEDULE B: TRANSPORTATION Auto Payment ............................................................................... $ $ $ $ $ ) .................................... $ $ Registration, License .................................................................... $ $ Maintenance.................................................................................. $ $ Fuel and Oil $ $ Commuting Expenses $ $ $ $ $ $ Auto Insurance (number of vehicles: Other Charges (Itemize) TOTAL Effective 09/01/2009, CN 10482-English page 5 American LegalNet, Inc. www.FormsWorkFlow.com Joint Marital Life Style Family, including _____ children SCHEDULE C: PERSONAL Current Life Style Yours and _____ children Food at Home & household supplies ............................................ $ $ Prescription Drugs ........................................................................ $ $ Non-prescription drugs, cosmetics, toiletries & sundries.............. $ $ School Lunch ................................................................................ $ $ Restaurants.................................................................................... $ $ Clothing. ....................................................................................... $ $ Dry Cleaning, Commercial Laundry............................................. $ $ Hair Care....................................................................................... $ $ Domestic Help .............................................................................. $ $ Medical (exclusive of psychiatric)* .............................................. $ $ Eye Care* ..................................................................................... $ $ Psychiatric/psychological/counseling* ......................................... $ $ Dental (exclusive of Orthodontic)*............................................... $ $ Orthodontic* ................................................................................. $ $ Medical Insurance (hospital, etc.)* ............................................... $ $ Club Dues and Memberships ........................................................ $ $ Sports and Hobbies ....................................................................... $ $ Camps. .......................................................................................... $ $ Vacations ...................................................................................... $ $ Children’s Private School Costs.................................................... $ $ Parent’s Educational Costs............................................................ $ $ Children’s Lessons (dancing, music, sports, etc.) ......................... $ $ Baby-sitting................................................................................... $ $ Day-Care Expenses....................................................................... $ $ Entertainment................................................................................ $ $ Alcohol and Tobacco .................................................................... $ $ Newspapers and Periodicals.......................................................... $ $ Gifts .............................................................................................. $ $ Contributions. ............................................................................... $ $ Payments to Non-Child Dependents ............................................. Prior Existing Support Obligations this family/other families (specify) .......................................................................... $ $ $ $ Tax Reserve (not listed elsewhere) ............................................... $ $ Life Insurance ............................................................................... $ $ Savings/Investment....................................................................... $ $ Debt Service (from page 7) (not listed elsewhere)........................ $ $ Parenting Time Expenses.............................................................. $ $ Professional Expenses (other than this proceeding)...................... $ $ Other (specify) .............................................................................. $ $ $ $ *unreimbursed only TOTAL Please Note: If you are paying expenses for a spouse and/or children not reflected in this budget, attach a schedule of such payments. Schedule A: Shelter ...................................................................................... Schedule B: Transportation .......................................................................... Schedule C: Personal .................................................................................... $ $ $ $ $ $ Grand Totals ................................................................................................. $ $ Effective 09/01/2009, CN 10482-English page 6 American LegalNet, Inc. www.FormsWorkFlow.com PART E - BALANCE SHEET OF ALL FAMILY ASSETS AND LIABILITIES STATEMENT OF ASSETS Date of purchase/acquisition. If Title to claim that asset is exempt, state Property reason and value of what is (H, W, J) claimed to be exempt Description 1. Bank Accounts, CD’s 3. Vehicles 4. Tangible Personal Property 5. Stocks and Bonds 6. Pension, Profit Sharing, Retirement Plan(s) 40l(k)s, etc. [list each employer] 7. IRAs 8. Businesses, Partnerships, Professional Practices 9. Date of Evaluation Mo./Day/ Yr. Real Property 2. Value $ Put * after exempt Life Insurance (cash surrender value) 10. Loans Receivable 11. Other (specify) $ TOTAL GROSS ASSETS: $ TOTAL SUBJECT TO EQUITABLE DISTRIBUTION: TOTAL NOT SUBJECT TO EQUITABLE DISTRIBUTION: $ Effective 09/01/2009, CN 10482-English page 7 American LegalNet, Inc. www.FormsWorkFlow.com Description 1. Other Short Term Debts 5. Date Revolving Charges 4. Total Owed Other Long Term Debts 3. Monthly Payment Real Estate Mortgages 2. STATEMENT OF LIABILITIES Name of If you contend liability should Responsible not be considered in equitable Party distribution, state reason (H, W, J) Contingent Liabilities TOTAL GROSS LIABILITIES: (excluding contingent liabilities) $ NET WORTH: (subject to equitable distribution) $ Effective 09/01/2009, CN 10482-English page 8 American LegalNet, Inc. www.FormsWorkFlow.com PART F - STATEMENT OF SPECIAL PROBLEMS Provide a brief narrative statement of any special problems involving this case: As example, state if the matter involves complex valuation problems (such as for a closely held business) or special medical problems of any family member etc. I certify that, other than in this form and its attachments, confidential personal identifiers have been redacted from documents now submitted to the court, and will be redacted from all documents submitted in the future in accordance with Rule 1:38-7(b). I certify that the foregoing information contained herein is true. I am aware that if any of the foregoing information contained herein is willfully false, I am subject to punishment. DATED: SIGNED: PART G - REQUIRED ATTACHMENTS CHECK IF YOU HAVE ATTACHED THE FOLLOWING REQUIRED DOCUMENTS 1. A full and complete copy of your last federal and state income tax returns with all schedules and attachments. (Part C-1) 2. Your last calendar year’s W-2 statements, 1099’s, K-1 statements. 3. Your three most recent pay stubs. 4. Bonus information including, but not limited to, percentage overrides, timing of payments, etc.; the last three statements of such bonuses, commissions, etc. (Part C) 5. Your most recent corporate benefit statement or a summary thereof showing the nature, amount and status of retirement plans, savings plans, income deferral plans, insurance benefits, etc. (Part C) 6. Affidavit of Insurance Coverage as required by Court Rule 5:4-2(f) (Part B-3) 7. List of all prior/pending family actions involving support, custody or Domestic Violence, with the Docket Number, County, State and the disposition reached. Attach copies of all existing Orders in effect. (Part B-5) 8. Attach details of each wage execution (Part C-5) 9. Schedule of payments made for a spouse and/or children not reflected in Part D. 10. Any agreements between the parties. 11. An Appendix IX Child Support Guideline Worksheet, as applicable, based upon available information. Effective 09/01/2009, CN 10482-English page 9 American LegalNet, Inc. www.FormsWorkFlow.com