COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. CHILD CUSTODY MEDIATIONIndex No. : INCOME STATEMENT : The following information will be used only for the purpose of determining the correct hourly fee to be Calendar No. charged for mediation services. # of children this couple: _______ : Plaintiff(s) PETITIONER 1. -against- JUDICIAL SUBPOENA : I prefer to pay the full fee of $100.00 per hour and not disclose my income at this time. : OR: 2. I swear the following statements are true to the best of my: knowledge: I ___am employed / ___I am not employed - ___full time ___part time Defendant(s) : . . . . . . .of. employer:. ._______________________________ Title ________________________ Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I ___have ___do not have other income. Income from OF (per month) Gross pay per month................................. $__________ THE PEOPLE job THE STATE OF NEW YORK Other income (per month) TO Child support $__________ Social Security A.F.D.C. benefits $__________ Any additional GREETINGS: $__________ $ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Total: other income...............$__________ , the Honorable at the Court TOTALCounty all sources: job + total other income)............................................................. $__________ (from of located at 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 __________________________________ Petitioner Date RESPONDENT Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to 1. OR: 2. the partyto pay thebehalf this subpoena was issued andanot disclose my incomeand thisdamages sustained as a I prefer on whose full fee of $100.00 per hour for maximum penalty of $50 at all time. result of your failure to comply. I swear the following statements are true to the best of my knowledge: Witness, Honorable , one of the Justices of the I ___am / ___I Court in employedCounty, am not employed - ___full time ___part time day of , 20 Name of employer: _______________________________ Title ________________________ I ___have ___do not have other income. Income from job (per month) Other income (per month) (Attorney must sign above and type name below) Gross pay per month................................. $__________ Child support $__________ Attorney(s) for Social Security $__________ A.F.D.C. benefits $__________ Office and P.O. Address Any additional $ Total: other income...............$__________ Telephone No.: TOTAL (from all sources: job + total other income)............................................................. $__________ Facsimile No.: _________________________________ E-Mail Address: Respondent Date Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com