COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. : JUDICIAL SUBPOENA FAMILY PART CASE INFORMATION STATEMENT Plaintiff(s) Attorney(s): Office Address Tel. No./Fax No. Attorney(s) for: -against- : : Plaintiff, vs. : SUPERIOR COURT OF NEW JERSEY CHANCERY DIVISION, FAMILY PART COUNTY Defendant. DOCKET NO. Defendant(s) CASE :INFORMATION STATEMENT ...................................................... OF ____________________________ NOTICE: THE 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 PEOPLE shall THE STATE20 days after the filing of the Answer or Appearance. Failure to file a Case Information OF be filed within OF NEW YORK Statement may result in the dismissal of a party’s pleadings. TO PART A - CASE INFORMATION: - Date of Statement Date of Divorce GREETINGS: (post-Judgment matters) Date(s) of Prior Statement(s) ISSUES IN DISPUTE: Cause of Action Custody Parenting Time Alimony and excuses being laid aside, you Child Support at the Court Equitable Distribution Counsel Fees , 20 Other at [be specific] in the , issues o'clock WE and each of you attend before Your Birthdate COMMAND YOU, that all business , the Honorable Party Birthdate of Other located at County of Date of Marriage inDate of Separation , on the room day of noon, and at any recessed orDate of Complaint to testify and give evidence as a witness in this action on the part of the adjourned date, Does an agreement exist between parties relative to any issue? summary (if oral). [ ] Yes [ ] No. If Yes, ATTACH a copy (if written) or a Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to 1. Name and Addresses of Parties: the party on _____________________________________________________________________________________________ Your Name whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Street Address _________________________________________________ City_________________ State/Zip_________ Other Party’s Name _______________________________________________________________________________________ Street Address _________________________________________________ City_________________ State/Zip_________ Witness, Honorable Court in Address, Birthdate and Person with whom children reside:20 County, day of , 2. Name, , one of the Justices of the a. Child(ren) From This Relationship Child’s Full Name Address Birthdate Person’s Name ________________________ _________________________________ ______________ _________________________ ________________________ _________________________________ (Attorney must sign above and type name below) ______________ _________________________ ________________________ _________________________________ ______________ _________________________ ________________________ _________________________________ ______________ _________________________ b. Child(ren) From Other Relationships Child’s Full Name Address ________________________ _________________________________ ________________________ _________________________________ ________________________ _________________________________ ________________________ _________________________________ Revised Family CIS [corrected copy] Adopted July 28, 2004 to be Effective September 1, 2004 Attorney(s) for Birthdate ______________ ______________ ______________ ______________ Office and P.O. Person’s Name _________________________ _________________________ _________________________ _________________________ Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : PART B - MISCELLANEOUS INFORMATION: - Index No. Calendar No. 1. Information about Employment (Provide Name & Address of Business, if Self-employed) Name of Employer/Business ___________________________ Address ___________________________________________ : JUDICIAL SUBPOENA Plaintiff(s) __________________________________________________ Name of Employer/Business ___________________________ Address ___________________________________________ -against: __________________________________________________ 2. Do you have Insurance obtained through Employment/Business? [ ] Yes [ ] No. Type of Insurance: 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:_________________________________ : ________________________________________________________________________________________________________ Defendant(s) : . .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 [ ]Yes [ ] No THE PEOPLE OF THE STATE OF NEW YORK 5. 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. TO PART C. - INCOME INFORMATION: Complete this section for self and (if known) for spouse. 1. LAST YEAR’S INCOME Yours Joint 1. Gross earned income last calendar (year) $______________ $______________ Spouse or Former Spouse $______________ column. $______________ $______________ $______________ 4. Net income (1 + 2-3) $______________ $______________ $______________ GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court 2. Unearned income (same year) $______________ $______________ $______________ located at County of (Fed., in3. Total Income Taxeson the incomeday ofState, room , paid on , 20 , at o'clock in the noon, and at any recessed F.I.C.A., and S.U.I.).to testify and give evidence as a witness in this action on the part of the If Joint Return, use middle or adjourned date, to this form a to comply with this subpoena is statement of as a contempt of court and (See Part G) ATTACHYour failurecorporate benefits statement as well as a punishableall fringe benefits of employment.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. of last year’s Federal and State Income Tax Returns. ATTACH W-2 statements, 1099’s, ATTACH a full and complete copy 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,[one of the ] Check if attached: Federal Tax Return [ ] Witness, Honorable Court in Justices of the County, 2. PRESENT EARNED INCOME AND EXPENSES day of , 20 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. Other Party (if known) (Attorney must sign above and type name below) $______________ $______________ Attorney(s) for *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. [ ] S.U.I. [ ] Other $______________ $______________ Office and P.O. Address 3. Net average weekly income (1 - 2) $______________ Telephone No.: 3. YOUR CURRENT YEAR-TO-DATE EARNED INCOME Provide Dates: From _____________ Facsimile No.: 1. GROSS EARNED INCOME: $ Number of Address: E-Mail Weeks_________ 2. TAX DEDUCTIONS: (Number of Dependents: ) $______________ To _____________ Mobile Tel. No.: Adopted 7/28/04 to be Effective 9/1/04 2 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : a. b. c. d. e. f. g. h. i. Federal Income Taxes N.J. Income Taxes Other State Income Taxes FICA Plaintiff(s) Medicare S.U.I. / S.D.I. -againstEstimated tax payments in excess of withholding a. b. c. d. e. f. g. h. i. TOTAL Index No. $___________________________ :$___________________________ Calendar No. $___________________________ :$___________________________ JUDICIAL SUBPOENA $___________________________ $___________________________ :$___________________________ $___________________________ :$___________________________ $___________________________ : 3. GROSS INCOME NET OF TAXES $ $___________________________ Defendant(s) : . .4. .OTHER .DEDUCTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..... .......... a. Hospitalization/Medical Insurance b. Life Insurance c. Union Dues d. 401(k) Plans THEe. Pension/Retirement Plans PEOPLE OF THE STATE OF NEW f. Other Plans—specify g. Charity TO h. Wage Execution i. Medical Reimbursement (flex fund) j. Other: a. b. c. d. e. f. g. h. i. j. YORK TOTAL GREETINGS: 5. NET YEAR-TO-DATE EARNED INCOME: If mandatory, check box $___________________________ [ ] $___________________________ [ ] $___________________________ [ ] $___________________________ [ ] $___________________________ [ ] $___________________________ [ ] $___________________________ [ ] $___________________________ [ ] $___________________________ [ ] $___________________________ [ ] $___________________________ $___________________________ NET AVERAGE EARNED YOU, that all business and excuses being laid aside, you and each of you attend before $___________________________ WE COMMAND INCOME PER MONTH: , the Honorable at the Court $___________________________ NET AVERAGE EARNED INCOME PER WEEK 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 YOUR YEAR-TO-DATE GROSS a witness in INCOME FROM the part of the 4. testify and give evidence as UNEARNED this action on 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) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Source How often Year to date amount the party on whose behalf this subpoena was issued for a maximum penaltypaid $50 and all damages sustained as a of __________________________________________________ __________________ $_______________ result of your failure to comply. __________________________________________________ __________________ $_______________ __________________________________________________ __________________________________________________ Witness, Honorable __________________________________________________ Court in County, day of , 20 __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ TOTAL GROSS UNEARNED INCOME YEAR TO DATE __________________ $_______________ __________________ the$_______________ , one of Justices of the __________________ $_______________ __________________ $_______________ __________________ $_______________ __________________ $_______________ __________________ and$_______________ (Attorney must sign above type name below) $_________________ Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Adopted 7/28/04 to be Effective 9/1/04 3 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. 1. : 5. ADDITIONAL INFORMATION: Calendar No. How often are you paid? ______________________________________________________________________________ 2. What is your annual salary? 3. -againstHave you received any raises in the current year? [ ]Yes [ ]No. If yes, :provide the date and the gross/net amount. ___________________________________________________________________________________________________ 4. Do you receive bonuses, commissions, or other compensation, including distributions, taxable or nontaxable, in addition to your regular salary? [ ]Yes [ ]No. If yes, explain:____________________________________ : ___________________________________________________________________________________________________ : JUDICIAL SUBPOENA $ _____________________________________________________________________ Plaintiff(s) : Defendant(s) 5. Did you receive a 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 NEW YORK THE PEOPLE OF THE STATE OFnot otherwise listed? [ ] Yes [ ] No If yes, explain. ______________________ ___________________________________________________________________________________________________ TO Have you received income from overtime work during either the current or immediate past calendar year? [ ]Yes 7. [ ]No If yes, explain. ____________________________________________________________ 8. Have you been awarded or granted stock options, restricted stock or any other non-cash compensation or entitlement during the current or immediate past calendar year? [ ]Yes [ ]No If yes, explain. __________________ GREETINGS: ___________________________________________________________________________________________________ 9. Have WE received any other supplemental compensation during either the current or aside, you and each of you attend before you COMMAND YOU, that all business and excuses being laid immediate past calendar year? [ ]Yes [ amounts , the Honorable ]No. If yes, state the date(s) of receipt and set forth the gross and netCourt received. Also describe the nature at the of of received._______________________________________________________ County any supplemental compensation located at __________________________________________________________________________ recessed in room , on the day of , 20 , at o'clock in the noon, and at any or adjourned date, to testify from give evidence as a witness in this action on the part of the or and unemployment, disability and/or social security during either the current 10. Have you received income immediate past calendar year? [ ]Yes [ ]No. If yes, state the date(s) of receipt and set forth the gross and net amounts received.____________________________________________________________________________________ 11. List Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the names of the dependents you claim:_____________________________________________________________ the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a 12. of you paying or receiving any result Areyour failure to comply. alimony? [ ]Yes [ ]No. If yes, how much and to whom paid or from whom received? ______________________________________________________________________________________ 13. Are you paying or receiving any child support? [ ]Yes [ ]No. If yes, list names of the children,the amount paid or Witness, Honorable , one of the Justices of the received for each child and to whom paid or from whom received. ___________________________________________ Court in County, day of , 20 ____________________________________________________________________________________________________ 14. Is there a wage execution in connection with support? [ ]Yes [ ]No If yes explain.______________________________ ___________________________________________________________________________________________________ (Attorney must sign above and type name below) 15. Has a dependent child of yours received income from social security, SSI or other government program during either the current or immediate past calendar year? [ ]Yes [ ]No. If yes, explain the basis and state the date(s) of receipt and set forth the gross and net amounts received _________________________________________________________ Attorney(s) for __________________________________________________________________________ 16. Explanation of Income or Other Information: __________________________________________________________________________ __________________________________________________________________________ Office and P.O. Address __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Telephone No.: __________________________________________________________________________ Facsimile No.: __________________________________________________________________________ E-Mail Address: Mobile Tel. No.: Adopted 7/28/04 to be Effective 9/1/04 4 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : PART D - MONTHLY EXPENSES (computed at 4.3 wks/mo.) - . : Index No. Calendar No. 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 JUDICIAL SUBPOENA Plaintiff(s) Family, including Yours and -against: _____ children _____ children SCHEDULE A: SHELTER If Tenant: : Rent…………………………………………………………. $___________________ $___________________ Heat (if not furnished)………………………………………. $___________________ $___________________ : Electric & Gas (if not furnished)……………………………. $___________________ $___________________ Renter’s Insurance…………………………………………... $___________________ $___________________ Defendant(s) : Parking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $___________________ . . . . . . . . . . . .(at. Apartment)……………………………………… . .$___________________ ..... Other charges (Itemize)……………………………………... $___________________ $___________________ If Homeowner: Mortgage ……………………………………………………. $___________________ THE PEOPLE OF THE STATE OFw/mortgage payment)… Real Estate Taxes (if not included NEW YORK $___________________ Homeowners Ins (if not included w/mortgage payment)… $___________________ Other Mortgages or Home Equity Loans …………………… $___________________ TO Heat (unless Electric or Gas)………………………………… $___________________ Electric & Gas………………………………………………... $___________________ Water & Sewer………………………………………………. $___________________ Garbage Removal……………………………………………. $___________________ GREETINGS: Snow Removal………………………………………………. $___________________ Lawn Care…………………………………………………… $___________________ WE COMMAND YOU, that all business and excuses being laid aside, Maintenance…………………………………………………. $___________________ you Repairs……………………………………………………….. $___________________ the Honorable at the Court Other located at County of Charges (Itemize)……………………………………... $___________________ $___________________ $___________________ $___________________ $___________________ $___________________ $___________________ $___________________ $___________________ $___________________ $___________________ and each of you attend $___________________ $___________________ $___________________ before in room , on the day of , 20 , at o'clock in the noon, and at any recessed Tenant or Homeowner: or adjourned date, to testify and give evidence as a witness in this action on the part of$___________________ the Telephone……………………………………………………... $___________________ Mobile/Cellular Telephone…………………………………... $___________________ $___________________ Service Contracts on Equipment…………………………….. $___________________ $___________________ Cable TV…………………………………………………….. $___________________ $___________________ Plumber/Electrician………………………………………….. $___________________of court and will make you liable to Your failure to comply with this subpoena is punishable as a contempt $___________________ Equipment & behalf this subpoena was issued for a $___________________ $___________________ the party on whose Furnishings…………………………………… maximum penalty of $50 and all damages sustained as a $___________________ result ofInternetfailure to comply. your Charges……………………………………………... $___________________ Other (itemize)………………………………………………. $___________________ $___________________ Witness, Honorable Court in County, , one of the Justices of the day of , 20 TOTAL $___________________ $___________________ (Attorney must sign above and type name below) SCHEDULE B: TRANSPORTATION Auto Payment……………………………………………….. Auto Insurance (number of vehicles: )……………………... Registration, License………………………………………... Maintenance……………………………………………….. Fuel and Oil…………………………………………………. Commuting Expenses………………………………………. Other Charges (Itemize)…………………………………….. TOTAL $___________________ $___________________ $___________________ $___________________ Attorney(s) for $___________________ $___________________ $___________________ $___________________ $___________________ $___________________ $___________________ $___________________ $___________________ $___________________ $___________________ $___________________ Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Adopted 7/28/04 to be Effective 9/1/04 5 American LegalNet, Inc. www.USCourtForms.com , COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. Joint Marital Life Style : Calendar Family, including _____children SCHEDULE C: PERSONAL……………………………………….. : Plaintiff(s) No. Current Life Style Yours and _____ children JUDICIAL SUBPOENA Food at Home & household supplies……………………….. $___________________ $___________________ -against: Prescription Drugs………………………………………….. $___________________ $___________________ Non-prescription drugs, cosmetics, toiletries & sundries…... $___________________ $___________________ : School Lunch……………………………………………….. $___________________ $___________________ Restaurants…………………………………………………. $___________________ $___________________ Clothing…………………………………………………….. $___________________ $___________________ : Dry Cleaning, Commercial Laundry……………………….. $___________________ $___________________ Hair Care……………………………………………………. $___________________ $___________________ Defendant(s) : Domestic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $___________________ . . . . . . . . . . . . . . Help………………………………………………. . .$___________________ ..... Medical (exclusive of psychiatric)*………………………… $___________________ $___________________ Eye Care*…………………………………………………… $___________________ $___________________ Psychiatric/psychological/counseling*……………………... $___________________ $___________________ Dental (exclusive of Orthodontic)*………………………… $___________________ $___________________ THE PEOPLE OF THE STATE OF NEW YORK Orthodontic*………………………………………………... $___________________ $___________________ Medical Insurance (hospital, etc.)*…………………………. $___________________ $___________________ TO Club Dues and Memberships………………………………. $___________________ $___________________ Sports and Hobbies………………………………………… $___________________ $___________________ Camps………………………………………………………. $___________________ $___________________ Vacations…………………………………………………… $___________________ $___________________ Children’s Private School Costs……………………………. $___________________ GREETINGS: Educational Costs…………………………………. $___________________ Parent’s $___________________ $___________________ Children’s Lessons (dancing, music, sports, etc.)…………... $___________________ $___________________ WE COMMAND YOU, that all business and excuses being laid aside, Baby-sitting…………………………………………………. $___________________you and each of you attend before $___________________ the Honorable Expenses…………………………………………. $___________________ at the Court Day-Care $___________________ Entertainment……………………………………………….. $___________________ $___________________ located at County of Alcohol and,Tobacco……………………………………….. , $___________________ the $___________________ recessed in room on the day of , 20 at o'clock in noon, and at any Newspapers and Periodicals………………………………… $___________________ $___________________ or adjourned date, to testify and give evidence as a witness in this action on the part of$___________________ the Gifts………………………………………………………… $___________________ Contributions……………………………………………….. $___________________ $___________________ Payments to Non-Child Dependents……………………….. $___________________ $___________________ Prior Existing Support Obligations this family/other Your (specify)……………………………………………. $___________________ familiesfailure to comply with this subpoena is punishable as a contempt of court and will make you liable to $___________________ $___________________ the partyTax Reserve (not listed elsewhere)…………………………. maximum penalty of $50 and all damages sustained as a on whose behalf this subpoena was issued for a $___________________ Life failure to comply. $___________________ result of yourInsurance……………………………………………… $___________________ Savings/Investment………………………………………… $___________________ $___________________ Debt Service (from page 7) (not listed elsewhere)…………. $___________________ $___________________ Witness, Honorable , one Parenting Time Expenses…………………………………... $___________________ of the Justices of the $___________________ this of $___________________ Court in Professional Expenses (other thanday proceeding)……….. $___________________ County, , 20 Other (specify)……………………………………………... $___________________ $___________________ *unreimbursed only…………………………………………………... TOTAL $___________________ $___________________ (Attorney must sign above and type name below) Please Note: If you are paying expenses for a spouse and/or children not reflected in this budget, attach a schedule of such payments. Attorney(s) for Schedule A: Shelter…………………………………………………… Schedule B: Transportation…………………………………………… Schedule C: Personal……………….…………………………………. $___________________ $___________________ $___________________ $___________________ $___________________ $___________________ Grand Totals…………………………………………………………... $___________________ $___________________ Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Adopted 7/28/04 to be Effective 9/1/04 6 American LegalNet, Inc. www.USCourtForms.com , COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : PART E - BALANCE SHEET OF ALL FAMILY ASSETS AND LIABILITIES Calendar No. Description Title to Property (H, W, J) -against- STATEMENT OF ASSETS Date of purchase/acquisition.: Plaintiff(s) If claim that asset is exempt, state reason and value of what : is claimed to be exempt Value Date of Put * after exempt Mo./Day/ Yr. JUDICIAL SUBPOENA $ Evaluation 1. Real Property : : 2. Bank Accounts, CD’s Defendant(s) : ...................................................... 3. Vehicles THE PEOPLE OF THE STATE OF NEW YORK TO Tangible Personal Property 4. GREETINGS: 5. Stocks and Bonds WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located County of Profit Sharing, Retirement Plan(s) at 6. Pension, 40l(k)s, in room etc. [list each employer] day of , on the , 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 7. IRAs Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to 8. Businesses, Partnerships, Professional Practices 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. 9. Life Insurance (cash surrender value) Witness, Honorable Court in County, , one of the Justices of the day of , 20 10. Loans Receivable (Attorney must sign above and type name below) 11. Other (specify) Attorney(s) for TOTAL GROSS ASSETS: TOTAL SUBJECT TO EQUITABLE DISTRIBUTION: TOTAL NOT SUBJECT TO EQUITABLE DISTRIBUTION: $__________________ $__________________ $__________________ Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Adopted 7/28/04 to be Effective 9/1/04 7 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : STATEMENT OF LIABILITIES Name of If you contend liability should : Responsible not be considered in equitable Party distribution, state reason : (H, W, J) Plaintiff(s) Description -against- Index No. Calendar No. Monthly Payment Total Owed Date JUDICIAL SUBPOENA : 1. Real Estate Mortgages : : 2. Other Long Term Debts Defendant(s) : ...................................................... 3. Revolving Charges THE PEOPLE OF THE STATE OF NEW YORK TO GREETINGS: WE Term Debts 4. Other Short 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 or5. Contingentdate, to testify and give evidence as a witness in this action on the part of the adjourned Liabilities 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, TOTAL GROSS LIABILITIES: $___________________ (excluding contingent liabilities) , one of the Justices of the NET WORTH: , 20 day of $___________________ (subject to equitable distribution) (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.: Adopted 7/28/04 to be Effective 9/1/04 8 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. 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 : Calendar No. - valuation problems (such as for a closely held business) or special medical problems of any family member etc. : Plaintiff(s) -against- JUDICIAL SUBPOENA : I certify that the foregoing information contained herein is true. I am aware that if any of the foregoing information contained therein is willfully false, I am subject to punishment. DATED: : SIGNED: _____________________ : Defendant(s) : ...................................................... PART G - REQUIRED ATTACHMENTS THE PEOPLE OF THE STATE OF NEW YORK CHECK IF YOU HAVE ATTACHED THE FOLLOWING REQUIRED DOCUMENTS TO A full and complete copy of your last federal and state income tax returns 1. with all schedules and attachments. (Part C-1) _____ 2. Your last calendar year’s W-2 statements, 1099’s, K-1 statements. _____ GREETINGS: recent pay stubs. 3. Your three most _____ 4. Bonus WE COMMAND YOU, that allto, percentage overrides, timing of payments, etc.; and each of you attend before information including, but not limited business and excuses being laid aside, you the last three _____ , the Honorable statements of such bonuses, commissions, etc. the C) at (Part Court located at County of 5. Your most recent corporate benefit statement or a summary thereof showing the nature, amount in roomstatus of retirementthe savings plans, income deferral plans, ,insurance benefits, etc.in theC) , on plans, day of , 20 at o'clock (Part noon, and at _____recessed any and or adjourned date, to testify and give evidence as a witness in this action on the part of the 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.YourB-5) (Part 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 8. Attach details of each wage execution (Part C-5) result of your failure to comply. 9. Schedule of payments made for a spouse and/or children not reflected in Part D. Witness, Honorable 10. Any agreements between the parties. day of Court in County, _____ , one of the Justices of the _____ , 20 11. An Appendix IX Child Support Guideline Worksheet, as applicable, based upon available information. _____ (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.: Adopted 7/28/04 to be Effective 9/1/04 9 American LegalNet, Inc. www.USCourtForms.com