SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF ---------------------------------------------------------------------X Plaintiff, STATEMENT OF NET WORTH DATED: Index No. Date Action Commenced: - against - Defendant. ----------------------------------------------------------------------X Complete all items, marking "NONE", "INAPPLICABLE" and "UNKNOWN", if appropriate STATE OF NEW YORK COUNTY OF _________ ) )ss.: ) _______________________, the Plaintiff/Defendant herein, being duly sworn, deposes and says that, subject to the penalties of perjury, the following is an accurate statement as of , 2015, of my net worth (assets of whatsoever kind and nature and wherever situated minus liabilities), statement of income from all sources and statement of assets transferred of whatsoever kind and nature and wherever situated and statement of expenses: I. FAMILY DATA (a) (b) (c) (d) Plaintiff's date of birth: Defendant's date of birth: Date married: Names and dates of birth of Child(ren) of the marriage: Minor child(ren) of prior marriage: Custody of child(ren) of prior marriage: Plaintiff's present address: Defendant's present address: (h) Occupation/Employer of Plaintiff: Occupation/Employer of Defendant: [UCS Rev. 6/2016] (e) (f) (g) American LegalNet, Inc. www.FormsWorkFlow.com II. EXPENSES: (List your current expenses on a monthly basis. If there has been any change in these expenses during the recent past please indicate). Items included under "other" should be listed separately with separate dollar amounts.) Housing: Monthly 1. 2. 3. 4. 5. 6. 7. Mortgage/Co-op Loan Home Equity Line of Credit/Second Mortgage Real Estate Taxes (if not included in mortgage payment) Homeowners/Renter's Insurance Homeowner's Association/Maintenance charges/Condominium Charges Rent Other TOTAL: HOUSING (a) (b) 1. 2. 3. 4. 5. 6. 7. 8. 9. Utilities: Monthly Fuel Oil/Gas Electric Telephone (land line) Mobile Phone Cable/Satellite TV Internet Alarm Water Other TOTAL: UTILITIES [UCS Rev. 6/2016] American LegalNet, Inc. www.FormsWorkFlow.com (c) 1. 2. 3. Food: Monthly Groceries Dining Out/Take Out Other TOTAL: FOOD (d) 1. 2. 3. 4. Clothing: Monthly Yourself Child(ren) Dry Cleaning Other TOTAL: CLOTHING (e) 1. 2. 3. 4. 5. Insurance: Monthly Life Fire, theft and liability and personal articles policy Automotive Umbrella Policy Medical Plan 5A. Medical Plan for yourself (Including name of carrier and name of insured) 5B. Medical Plan for children (Including name of carrier and name of insured) 6. 7. 8. Dental Plan Optical Plan Disability [UCS Rev. 6/2016] American LegalNet, Inc. www.FormsWorkFlow.com 9. 10. 11. Worker's Compensation Long Term Care Insurance Other TOTAL: INSURANCE (f) 1. 2. 3. 4. 5. 6. 7. Unreimbursed Medical: Monthly Medical Dental Optical Pharmaceutical Surgical, Nursing, Hospital Psychotherapy Other TOTAL: UNREIMBURSED MEDICAL (g) 1. 2. 3. 4. 5. 6. Household Maintenance: Monthly Repairs/Maintenance Gardening/landscaping Sanitation/carting Snow Removal Extermination Other TOTAL: HOUSEHOLD MAINTENANCE (h) 1. 2. 3. 4. Household Help: Monthly Domestic (housekeeper, etc.) Nanny/Au Pair/Child Care Babysitter Other TOTAL: HOUSEHOLD HELP [UCS Rev. 6/2016] American LegalNet, Inc. www.FormsWorkFlow.com (i) 1. 2. 3. 4. 5. 6. Automobile: Monthly (List a date for each car separately) Year:______ Make:________ Personal:_____ Business:________ Lease or Loan Payments (indicate lease term) Gas and Oil Repairs Car Wash Parking and tolls Other TOTAL: AUTOMOTIVE (j) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Education Costs: Monthly Nursery and Pre-school Primary and Secondary College Post-Graduate Religious Instruction School Transportation School Supplies/Books School Lunches Tutoring School Events Child(ren)'s extra-curricular and educational enrichment activities (Dance, Music, Sports, etc.) Other TOTAL: EDUCATION (k) 1. 2. Recreational: Monthly Vacations Movies, Theatre, Ballet, Etc. [UCS Rev. 6/2016] American LegalNet, Inc. www.FormsWorkFlow.com 3. 4. 5. 6. 7. 8. 9. Music (Digital or Physical Media) Recreation Clubs and Memberships Activities for yourself Health Club Summer Camp Birthday party costs for your child(ren) Other TOTAL: RECREATIONAL (l) 1. 2. 3. 4. 5. 6. Income Taxes: Monthly Federal State City Social Security and Medicare Number of dependents claimed in prior tax year List any refund received by you for prior tax year TOTAL: INCOME TAXES (m) 1. 2. 3. 4. 5. 6. 7. 8. 9. Miscellaneous: Monthly Beauty parlor/barber/Spa Toiletries/Non-Prescription Drugs Books, magazines, newspapers Gifts to others Charitable contributions Religious organizations dues Union and organization dues Commutation expenses Veterinarian/pet expenses [UCS Rev. 6/2016] American LegalNet, Inc. www.FormsWorkFlow.com 10. 11. 12. 13. 14. Child support payments (for Child(ren) of a prior marriage or relationship pursuant to court order or agreement) Alimony and maintenance payments (prior marriage pursuant to court order or agreement) Loan payments Unreimbursed business expenses Safe Deposit Box rental fee TOTAL: MISCELLANEOUS (n) 1. 2. 3. Other: Monthly TOTAL: OTHER TOTAL: MONTHLY EXPENSES [UCS Rev. 6/2016] American LegalNet, Inc. www.FormsWorkFlow.com III. (a) GROSS INCOME INFORMATION: Gross (total) income - as should have been or should be reported in the most recent Federal income tax return. (State whether your income has changed during the year preceding date of this affidavit. If so, please explain.) Attach most recent W-2, 1099s, K1s and income tax returns. List any amount deducted from gross income for retirement benefits or tax deferred savings. (b) To the extent not already included in gross income in (a) above: 1. Investment income, including interest and dividend income, reduced by sums expended in connection with such investment 2. Worker's compensation (indicate percentage of amount due to lost wages) 3. Disability benefits (indicate percentage of amount due to lost wages) 4. Unemployment insurance benefits 5. Social Security benefits 6. Supplemental Security Income 7. Public assistance 8. Food stamps 9. Veterans benefits 10. Pensions and retirement benefits 11. Fellowships and stipends 12. Annuity payments (c) (d) (e) If any child or other member of your household is employed, set forth name and that person's annual income: List any maintenance and/or child support you are receiving pursuant to court order or agreement Other: [UCS Rev. 6/2016] American LegalNet, Inc. www.FormsWorkFlow.com IV. ASSETS (If any asset