Appendix V 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 DOCKET NO. CASE INFORMATION STATEMENT OF Plaintiff, vs. 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. INSTRUCTIONS: The Case Information Statement is a document which is filed with the court setting forth the financial details of your case. The required information includes your income, your spouse's/partner's income, a budget of your joint life style expenses, a budget of your current life style expenses including the expenses of your children, if applicable, an itemization of the amounts which you may be paying in support for your spouse/partner or children if you are contributing to their support, a summary of the value of all assets referenced on page 8 ­ It is extremely important that the Case Information Statement be as accurate as possible because you are required to certify that the contents of the form are true. It helps establish your lifestyle which is an important component of alimony/spousal support and child support. The monthly expenses must be reviewed and should be based on actual expenditures such as those shown from checkbook registers, bank statements or credit card statements from the past 24 months. The asset values should be taken, if possible, from actual appraisals or account statements. If the values are estimates, it should be clearly noted that they are estimates. According to the Court Rules, you must update the Case Information Statement as your circumstances change. For example, if you move out of your residence and acquire your own apartment, you should file an Amended Case Information Statement showing your new rental and other living expenses. It is also very important that you attach copies of relevant documents as required by the Case Information Statement, including your most recent tax returns with W-2 forms, 1099s and your three (3) most recent paystubs. If a request has been made for college or post-secondary school contribution, you must also attach all relevant information pertaining to that request, including but not limited to documentation of all costs and reimbursements or assistance for which contribution is sought, such as invoices or receipts for tuition, board and books; proof of enrollment; and proof of all financial aid, scholarships, grants and student loans obtained. Revised to be effective September 1, 2013, CN: 10482 (Court Rules Appendix V) page 1 of 10 American LegalNet, Inc. www.FormsWorkFlow.com Part A - Case Information: Date of Statement Date of Divorce, Dissolution of Civil Union or Termination of Domestic Partnership (post-Judgment matters) Date(s) of Prior Statement(s) Your Birthdate Birthdate of Other Party Date of Marriage, or entry into Civil Union or Domestic Partnership Date of Separation Date of Complaint Does an agreement exist between parties relative to any issue? If Yes, ATTACH a copy (if written) or a summary (if oral). 1. Name and Addresses of Parties: Your Name Street Address Other Party's Name Street Address 2. Name, Address, Birthdate and Person with whom children reside: a. Child(ren) From This Relationship Child's Full Name Address Issues in Dispute: Cause of Action Custody Parenting Time Alimony Child Support Equitable Distribution Counsel Fees Other issues (be specific) Yes No. City State/Zip City State/Zip Birthdate Person's Name b. Child(ren) From Other Relationships Child's Full Name Address Birthdate Person's Name Part B - Miscellaneous Information: 1. Information about Employment (Provide Name & Address of Business, if Self-employed) Name of Employer/Business Name of Employer/Business 2. Do you have Insurance obtained through Employment/Business? Yes Medical Other (explain) No; Dental Yes No; Prescription Drug Address Address Yes Yes No. No; Life Type of Insurance: Yes No; Disability Yes No Is Insurance available through Employment/Business? Explain: Yes No 3. ATTACH Affidavit of Insurance Coverage as required by Court Rule 5:4-2 (f) (See Part G) Revised to be effective September 1, 2013, CN: 10482 (Court Rules Appendix V) page 2 of 10 American LegalNet, Inc. www.FormsWorkFlow.com 4. Additional Identification: Confidential Litigant Information Sheet: Filed Yes No 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. Part C. - Income Information: Complete this section for self and (if known) for other party. 1. Last Year's Income Yours 1. Gross earned income last calendar (year) 2. Unearned income (same year) 3. Total Income Taxes paid on income (Fed., State, F.I.C.A., and S.U.I.). If Joint Return, use middle column. 4. Net income (1 + 2 - 3) $ $ $ $ $ $ Joint Other Party $ $ $ $ $ $ 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) Federal Tax Return State Tax Return W-2 Other Check if attached: 2. Present Earned Income and Expenses 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. S.U.I. 3. Net average weekly income (1 - 2) $ Other $ $ $ Other Party (if known) $ 3. Your Current Year-to-Date Earned Income Provide Dates: From 1. GROSS EARNED INCOME: $ 2. TAX DEDUCTIONS: (Number of Dependents: a. Federal Income Taxes b. N.J. Income T