F.C.A. §§413-1, 424-a; Art. 5-B D.R.L. §§236-B, 240 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF ............................................................................................. In the Matter of a Proceeding for Support (Commissioner of Social Services, Assignor, on behalf of , Assignee) Petitioner -againstRespondent. ............................................................................................. Form 4-17 (Financial Disclosure Affidavit) 10/2012 Docket No. FINANCIAL DISCLOSURE AFFIDAVIT Notice: Your signature on this form must be notarized. You are required to attach to this form the following documents: · Current and representative paycheck stub(s); · Copies of your most recently filed state and federal income tax returns, including all forms; · A copy of the W-2 wage and tax statement(s) submitted with the returns OR, if you did not file tax returns, a copy of your W-2 form for the most recent year for which you filed tax returns; · Information relating to health insurance plans available to you for the provision of insurance, health care, dental care, optical care, prescription drug and other pharmaceutical and health-related benefits for the child(ren) for whom support is sought, including the costs for adding the child(ren) to such plans; and · Information relating to accident and life insurance plans. STATE OF NEW YORK ) ):ss.: COUNTY OF ) I, _________________________________, the (Petitioner) (Respondent) herein, residing at ______________ __________________________________,1 being duly sworn, depose and say that the following is an accurate 1 Unless ordered confidential, pursuant to Family Court Act §154-b, because of a risk that disclosure would place the health, safety or liberty of the party at risk. See Form GF-21 and GF-21a, available at www.nycourts.gov. American LegalNet, Inc. www.FormsWorkFlow.com Form 4-17 Page 2 statement of my income from all sources, my liabilities, my assets and my net worth, from whatever sources, and whatever kind and nature, and wherever situated: I. INCOME FROM ALL SOURCES: The correct amount of the child support obligation is presumed to be a percentage of income as defined by law. The percentages are set forth in Addendum A. Other pertinent information is set forth in Addenda B and C. List your income from all sources as follows: a. Wages and Salaries (as reportable on Federal and State income tax returns): 1 Employer and address ______________________________________________________________ 2. Hours worked per week ______ 3. Gross salary/wages (G Weekly G Bi-weekly G Monthly G Semi­monthly G Annual) G $________ 4. Deductions: a. Social Security/Medicare Tax a. $________ b. Federal Income Tax b. $________ c. New York State Tax c. $________ d. NYC/Yonkers Tax d. $________ e. Other payroll deductions ________________________ e. $________ ________________________ $________ ________________________ $________ 5 . Number of members in household _______ 6. Number of dependents _______ 7. Income of other members of household $________ per __________ $________ per __________ NOTE: ATTACH INFORMATION FOR ADDITIONAL EMPLOYERS ON SEPARATE PAGES. b. Self-Employment Income (Describe and list self- employment income; attach to this form the most recently filed Federal and State income tax returns, including all schedules): ________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ c. Interest/Dividend Income: ________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ d. Other Income/ Benefits: 1. Workers Compensation 2. Disability Benefits 3. Unemployment Insurance Benefits 4. Social Security Benefits 5. Veterans Benefits 6. Pensions and Retirement Benefits 7. Fellowships/Stipends/Annuities 8. Supplemental Security Income (SSI) 1. 2. 3. 4. 5. 6. 7. 8. $________ per __________ $________ per __________ $________ per __________ $________ per __________ $________ per __________ $________ per __________ $________ per __________ $________ per __________ American LegalNet, Inc. www.FormsWorkFlow.com Form 4-17 Page 3 9. Public Assistance 10. Food Stamps 9. $________ per __________ 10. $________ per __________ e. Income from other sources: (List here and explain any other income including but not limited to: nonincome producing assets; employment "perks" and reimbursed expenses to the extent that they reduce personal expenses; fringe benefits as a result of employment; periodic income, personal injury settlements; non-reported income; and money, goods and services provided by relatives and friends): ____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ II. ASSETS: The Court can consider the assets of the custodial parent and/or the non-custodial parent in its award of child support. List your assets as follows: a. Savings account balance (Name of bank: _________________________ ) a. $_______________ b. Checking account balance (Name of bank: ________________________) b. $_______________ c. Automobile(s) (Year and make: ________________________________ ) c. $_______________ Loan information ____________________________________________ d. Residence owned (Address: ____________________________________) d. $_______________ e. Other real estate owned _______________________________________ e. $_______________ f. Other assets (For example: stocks, bonds, trailers, boat, etc.) __________ f. $_______________ ___________________________________________________________ g. Driver's, professional, recreational, sporting and other licenses and permits held (provide name of issuing agency, license number and attach a copy if possible) __________________________________________ _____________________________________________________________________________________ NOTE: ATTACH TO THIS FORM ANY INFORMATION AS TO ANY ADDITIONAL ASSETS. III. DEDUCTIONS FROM INCOME: The Court allows certain deductions from income prior to applying the child support percentages. List the deductions that apply to you as follows: a. b. c. d. e. f. g. h. Unr