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New York Codes Rules Regulations (Last Updated: March 27,2024) |
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TITLE 22. Judiciary |
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Subtitle D. Forms |
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Chapter III. Supreme and County Court Forms |
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Subchapter A. Forms Authorized by Section 202.16(b) |
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Statement of net worth (DRL 236) |
Complete all items, marking “NONE,” “INAPPLICABLE” and “UNKNOWN,” (if appropriate) STATE OF COUNTY OF SS.: ____, the (Petitioner) (Respondent) (Plaintiff) (Defendant) herein, being duly sworn, deposes and says that the following is an accurate statement as of __, 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: I. FAMILY DATA: (a) Husband's age __ (b) Wife's age __ (c) Date married __ (d) Date (separated) (divorced) __ (e) Number of dependent children under 21 years __ (f) Names and ages of children ____________ ____________ ____________ ____________ (g) Custody of children __ Husband __ Wife (h) Minor children of a prior marriage: __ Husband __ Wife (i) (Husband)(Wife) (paying)(receiving) $_ as alimony (maintenance) and/or $ _ child support in connection with prior marriage (j) Custody of children of prior marriage: Name Address (k) Is marital residence occupied by Husband __ Wife __ Both __ (l) Husband's present address Wife’s present address (m) Occupation of Husband Occupation of Wife (n) Husband's employer (o) Wife's employer (p) Education, training and skills [Include dates of attainment of degrees, etc.] Husband Wife (q) Husband's health (r) Wife's health (s) Children's health II. EXPENSES: (You may elect to list all expenses on a weekly basis or all expenses on a monthly basis, however, you must be consistent. If any items are paid on a monthly basis, divide by 4.3 to obtain weekly payments; if any items are paid on a weekly basis, multiply by 4.3 to obtain monthly payment. Attach additional sheet, if needed. Items included under “Other” should be listed separately with separate dollar amounts.) Expenses listed [ ] weekly [ ] monthly (a) Housing 1. Rent __ 2. Mortgage and amortization __ 3. Real estate taxes __ 4. Condominium charges __ 5. Cooperative apartment maintenance __ Total: Housing $ __ (b) Utilities 1. Fuel Oil __ 2. Gas __ 3. Electricity __ 4. Telephone __ 5. Water __ Total: Utilities $ __ (c) Food 1. Groceries __ 2. School lunches __ 3. Lunches at work __ 4. Dining out __ 5. Liquor/alcohol __ 6. Home entertainment __ 7. Other __ __ Total: Food $ __ (d) Clothing 1. Husband __ 2. Wife __ 3. Children __ 4. Other __ __ Total: Clothing $ __ (e) Laundry 1. Laundry at home __ 2. Dry cleaning __ 3. Other __ ____ Total: Laundry $ __ (f) Insurance 1. Life __ 2. Homeowner’s/tenant’s __ 3. Fire, theft and liability __ 4. Automotive __ 5. Umbrella policy __ 6. Medical plan __ 7. Dental plan __ 8. Optical plan __ 9. Disability __ 10. Workers' compensation 11. Other __ ____ Total: Insurance $ __ (g) Unreimbursed medical 1. Medical __ 2. Dental __ 3. Optical __ 4. Pharmaceutical __ 5. Surgical, nursing, hospital __ 6. Other __ __ Total: Unreimbursed medical $ __ (h) Household maintenance 1. Repairs __ 2. Furniture, furnishings, housewares __ 3. Cleaning supplies __ 4. Appliances, including maintenance __ 5. Painting __ 6. Sanitation/carting __ 7. Gardening/landscaping __ 8. Snow removal __ 9. Extermination __ 10. Other __ __ Total: Household maintenance $ __ (i) Household help 1. Babysitter __ 2. Domestic (housekeeper, maid, etc.) __ 3. Other __ __ Total: Household help $ __ (j) Automotive Year: __ Make: ___ Personal: __ Business: __ Year: __ Make: ___ Personal: __ Business: __ Year: __ Make: ___ Personal: __ Business: __ 1. Payments __ 2. Gas and oil __ 3. Repairs __ 4. Car wash __ 5. Registration and license __ 6. Parking and tolls __ 7. Other __ Total: Automotive $ __ (k) Educational 1. Nursery and pre-school __ 2. Primary and secondary __ 3. College __ 4. Post-graduate __ 5. Religious instruction __ 6. School transportation __ 7. School supplies/books __ 8. Tutoring __ 9. School events __ 10. Other __ __ Total: Educational $ __ (l) Recreational 1. Summer camp __ 2. Vacations __ 3. Movies __ 4. Theatre, ballet, etc. __ 5. Video rentals __ 6. Tapes, CD’s, etc. __ 7. Cable television __ 8. Team sports __ 9. Country club/pool club __ 10. Health club __ 11. Sporting goods __ 12. Hobbies __ 13. Music/dance lessons __ 14. Sports lessons __ 15. Birthday parties __ 16. Other __ __ Total: Recreational $ __ (m) Income taxes 1. Federal __ 2. State __ 3. City __ 4. Social Security and Medicare __ Total: Income taxes $ __ (n) Miscellaneous 1. Beauty parlor/barber __ 2. Beauty aids/cosmetics, drug items __ 3. Cigarettes/tobacco __ 4. Books, magazines, newspapers __ 5. Children’s allowances __ 6. Gifts __ 7. Charitable contributions __ 8. Religious organization dues __ 9. Union and organization dues __ 10. Commutation and transportation __ 11. Veterinarian/pet expenses __ 12. Child support payments (prior marriage) __ 13. Alimony and maintenance payments (prior marriage) __ 14. Loan payments __ 15. Unreimbursed business expenses __ Total: Miscellaneous $ __ (o) Other 1. __ __ 2. __ __ 3. __ __ 4. __ __ Total: Other $ __ TOTAL EXPENSES: __ III. GROSS INCOME: (State source of income and annual amount. Attach additional sheet, if needed.) (a) Salary or wages: (State whether income has changed during the year preceding date of this affidavit __. If so, set forth name and address of all employers during preceding year and average weekly wage paid by each. Indicate overtime earnings separately. Attach previous year's W-2 or income tax return.) __ __ (b) Weekly deductions: 1. Federal tax __ 2. New York State tax __ 3. Local tax __ 4. Social Security __ 5. Medicare __ 6. Other payroll deductions ( specify ) __ (c) Social Security number ________ (d) Number and names of dependents claimed: ____ (e) Bonus, commissions, fringe benefits ( use of auto, memberships, etc. ) __ (f) Partnership, royalties, sale of assets ( income and installment payments ) __ (g) Dividends and interest ( state whether taxable or not ) __ (h) Real estate ( income only ) __ (i) Trust, profit sharing and annuities ( principal distribution and income ) __ (j) Pension ( income only ) __ (k) Awards, prizes, grants ( state whether taxable ) __ (l) Bequests, legacies and gifts __ (m) Income from all other sources ( including alimony, maintenance or child support from prior marriage ) __ (n) Tax preference items: 1. Long term capital gain deduction __ 2. Depreciation, amortization or depletion __ 3. Stock options — excess of fair market value over amount paid __ (o) If any child or other member of your household is employed, set forth name and that person's annual income __ (p) Social Security __ (q) Disability benefits __ (r) Public assistance __ (s) Other __ TOTAL INCOME: __ IV. ASSETS. (If any asset is held jointly with spouse or another, so state, and set forth your respective shares. Attach additional sheets, if needed.) A. Cash accounts Cash 1.1 a. Location b. Source of funds c. Amount $__ Total: Cash $__ Checking accounts 2.1 a. Location b. Account number c. Title holder d. Date opened e. Source of funds f. Balance $__ 2.2 a. Financial institution b. Account number c. Title holder d. Date opened e. Source of funds f. Balance $__ Total: Checking $__ Savings accounts (including individual, joint, totten trust, certificates of deposit, treasury notes) 3.1 a. Financial institution b. Account number c. Title holder d. Type of account e. Date opened f. Source of funds g. Balance $__ 3.2 a. Financial institution b. Account number c. Title holder d. Type of account e. Date opened f. Source of funds g. Balance $__ Total: Savings $__ Security deposits, earnest money, etc. 4.1 a. Location b. Title owner c. Type of deposit d. Source of funds e. Date of deposit f. Amount $__ Total: Security deposits, etc. $__ Other 5.1 a. Location b. Title owner c. Type of account d. Source of funds e. Date of deposit f. Amount $__ Total: Other $__ Total: Cash accounts $__ B. Securities Bonds, notes, mortgages 1.1 a. Description of security b. Title holder c. Location d. Date of acquisition e. Original price or value f. Source of funds to acquire g. Current value $__ Total: Bonds, notes, etc. $__ Stocks, options and commodity contracts 2.1 a. Description of security b. Title holder c. Location d. Date of acquisition e. Original price or value f. Source of funds to acquire g. Current value $__ 2.2 a. Description of security b. Title holder c. Location d. Date of acquisition e. Original price or value f. Source of funds to acquire g. Current value $__ 2.3 a. Description of security b. Title holder c. Location d. Date of acquisition e. Original price or value f. Source of funds to acquire g. Current value $__ Total: Stocks, options, etc. $__ Broker margin accounts 3.1 a. Name and address of broker b. Title holder c. Date account opened d. Original value of account e. Source of funds f. Current value $__ Total: Margin accounts $__ Total: Value of securities: $__ C. Loans to others and accounts receivable 1.1 a. Debtor’s name and address b. Original amount of loan or debt c. Source of funds from which loan made or origin of debt d. Date payment(s) due e. Current amount due $__ 1.2 a. Debtor’s name and address b. Original amount of loan or debt c. Source of funds from which loan made or origin of debt d. Date payment(s) due e. Current amount due $__ Total: Loans and accounts receivable $__ D. Value of interest in any business 1.1 a. Name and address of business b. Type of business (corporate, partnership, sole proprietorship or other) c. Your capital contribution d. Your percentage of interest e. Date of acquisition f. Original price or value g. Source of funds to acquire h. Method of valuation i. Other relevant information j. Current net worth of business $ __ Total: Value of business interest $__ E. Cash surrender value of life insurance 1.1 a. Insurer’s name and address b. Name of insured c. Policy number d. Face amount of policy e. Policy owner f. Date of acquisition g. Source of funding to acquire h. Current cash surrender value $__ Total: Value of life insurance $__ F. Vehicles (automobile, boat, plane, truck, camper, etc.) 1.1 a. Description b. Title owner c. Date of acquisition d. Original price e. Source of funds to acquire f. Amount of current lien unpaid g. Current fair market value $__ 1.2 a. Description b. Title owner c. Date of acquisition d. Original price e. Source of funds to acquire f. Amount of current lien unpaid g. Current fair market value $__ Total: Value of vehicles $__ G. Real estate (including real property, leaseholds, life estates, etc. at market value—do not deduct any mortgage) 1.1 a. Description b. Title owner c. Date of acquisition d. Original price e. Source of funds to acquire f. Amount of mortgage or lien unpaid g. Estimated current market value $__ 1.2 a. Description b. Title owner c. Date of acquisition d. Original price e. Source of funds to acquire f. Amount of mortgage or lien unpaid g. Estimated current market value $__ 1.3 a. Description b. Title owner c. Date of acquisition d. Original price e. Source of funds to acquire f. Amount of mortgage or lien unpaid g. Estimated current market value $__ Total: Value of real estate $__ H. Vested interests in trusts (pension, profit sharing, legacies, deferred compensation and others) 1.1 a. Description of trust b. Location of assets c. Title owner d. Date of acquisition e. Original investment f. Source of funds g. Amount of unpaid liens h. Current value $__ 1.2 a. Description of trust b. Location of assets c. Title owner d. Date of acquisition e. Original investment f. Source of funds g. Amount of unpaid liens h. Current value $__ Total: Vested interest in trusts $__ I. Contingent interests (stock options, interests subject to life estates, prospective inheritances, etc.) 1.1 a. Description b. Location c. Date of vesting d. Title owner e. Date of acquisition f. Original price or value g. Source of funds to acquire h. Method of valuation i. Current value $__ Total: Contingent interests $__ J. Household furnishings 1.1 a. Description b. Location c. Title owner d. Original price e. Source of funds to acquire f. Amount of lien unpaid g. Current value $__ Total: Household furnishings $__ K. Jewelry, art, antiques, precious objects, gold and precious metals (only if valued at more than $500) 1.1 a. Description b. Title owner c. Location d. Original price or value e. Source of funds to acquire f. Amount of lien unpaid g. Current value $__ 1.2 a. Description b. Title owner c. Location d. Original price or value e. Source of funds to acquire f. Amount of lien unpaid g. Current value $__ Total: Jewelry, art, etc.: $__ L. Other (e.g., tax shelter investments, collections, judgments, causes of action, patents, trademarks, copyrights, and any other asset not hereinabove itemized) 1.1 a. Description b. Title owner c. Location d. Original price or value e. Source of funds to acquire f. Amount of lien unpaid g. Current value $__ 1.2 a. Description b. Title owner c. Location d. Original price or value e. Source of funds to acquire f. Amount of lien unpaid g. Current value $__ Total: Other $__ TOTAL: ASSETS $___ V. LIABILITIES A. Accounts payable 1.1 a. Name and address of creditor b. Debtor c. Amount of original debt d. Date of incurring debt e. Purpose f. Monthly or other periodic payment g. Amount of current debt $__ 1.2 a. Name and address of creditor b. Debtor c. Amount of original debt d. Date of incurring debt e. Purpose f. Monthly or other periodic payment g. Amount of current debt $__ 1.3 a. Name and address of creditor b. Debtor c. Amount of original debt d. Date of incurring debt e. Purpose f. Monthly or other periodic payment g. Amount of current debt $__ 1.4 a. Name and address of creditor b. Debtor c. Amount of original debt d. Date of incurring debt e. Purpose f. Monthly or other periodic payment g. Amount of current debt $__ 1.5 a. Name and address of creditor b. Debtor c. Amount of original debt d. Date of incurring debt e. Purpose f. Monthly or other periodic payment g. Amount of current debt $__ Total: Accounts payable $__ B. Notes payable 1.1 a. Name and address of note holder b. Debtor c. Amount of original debt d. Date of incurring debt e. Purpose f. Monthly or other periodic payment g. Amount of current debt $__ 1.2 a. Name and address of note holder b. Debtor c. Amount of original debt d. Date of incurring debt e. Purpose f. Monthly or other periodic payment g. Amount of current debt $__ Total: Notes payable $__ C. Installment accounts payable (security agreements, chattel mortgages) 1.1. a. Name and address of creditor b. Debtor c. Amount of original debt d. Date of incurring debt e. Purpose f. Monthly or other periodic payment g. Amount of current debt $__ 1.2 a. Name and address of creditor b. Debtor c. Amount of original debt d. Date of incurring debt e. Purpose f. Monthly or other periodic payment g. Amount of current debt $__ Total: Installment accounts $__ D. Brokers’ margin accounts 1.1 a. Name and address of broker b. Amount of original debt c. Date of incurring debt d. Purpose e. Monthly or other periodic payment f. Amount of current debt $__ Total: Brokers’ margin accounts $__ E. Mortgages payable on real estate 1.1 a. Name and address of mortgagee b. Address of property mortgaged c. Mortgagor(s) d. Original debt e. Date of incurring debt f. Monthly or other periodic payment g. Maturity date h. Amount of current debt $__ 1.2 a. Name and address of mortgagee b. Address of property mortgaged c. Mortgagor(s) d. Original debt e. Date of incurring debt f. Monthly or other periodic payment g. Maturity date h. Amount of current debt $__ Total: Mortgages payable $__ F. Taxes payable 1.1 a. Description of tax b. Amount of tax c. Date due Total: Taxes payable $__ G. Loans on life insurance policies 1.1 a. Name of insurer b. Amount of loan c. Date incurred d. Purpose e. Name of borrower f. Monthly or other periodic payment g. Amount of current debt $__ Total: Life insurance loans $__ H. Other liabilities 1.1 a. Description b. Name and address of creditor c. Debtor d. Original amount of debt e. Date incurred f. Purpose g. Monthly or other periodic payment h. Amount of current debt $__ 1.2 a. Description b. Name and address of creditor c. Debtor d. Original amount of debt e. Date incurred f. Purpose g. Monthly or other periodic payment h. Amount of current debt $__ Total: Other liabilities $__ TOTAL LIABILITIES: $___ NET WORTH TOTAL ASSETS: $ ___ TOTAL LIABLITIES: (minus) ($ ___ ) NET WORTH: $___ VI. ASSETS TRANSFERRED: (List all assets transferred in any manner during the preceding three years, or length of the marriage, whichever is shorter [transfers in the routine course of business which resulted in an exchange of assets of substantially equivalent value need not be specifically disclosed where such assets are otherwise identified in the statement of net worth].) To whom transferred Description and relationship to of property transferee Date of transfer Value ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ VII. SUPPORT REQUIREMENTS: (a) Deponent is at present (paying)(receiving) $ __ per (week)(month), and prior to separation (paid)(received) $ __ per (week)(month), to cover expenses for . These payments are being made (voluntarily)(pursuant to court order or judgment)(pursuant to separation agreement), and there are (no) arrears outstanding (in the sum of $ __ to date). (b) Deponent requests for support of each child $ __ per (week)(month). Total for children $ __ . (c) Deponent requests for support of self $ __ per (week)(month). (d) The day of the (week)(month) on which payment should be made is __ . VIII. COUNSEL FEE REQUIREMENTS: (a) Deponent requests for counsel fee and disbursements the sum of $ __ . (b) Deponent has paid counsel the sum of $ __ and has agreed with counsel concerning fees as follows: (c) There is (not) a retainer agreement or written agreement relating to payment of legal fees. (A copy of any such agreement must be annexed.) IX. ACCOUNTANT AND APPRAISAL FEES REQUIREMENTS: (a) Deponent requests for accountants' fees and disbursements the sum of $ __. (Include basis for fee, e.g., hourly rate, flat rate.) (b) Deponent requests for appraisal fees and disbursements the sum of $ __ . (Include basis for fee, e.g., hourly rate, flat rate.) (c) Deponent requires the services of an accountant for the following reasons: (d) Deponent requires the services of an appraiser for the following reasons: X. Other data concerning the financial circumstances of the parties that should be brought to the attention of the Court are: The foregoing statements and a rider consisting of __ page(s) annexed hereto and made part hereof, have been carefully read by the undersigned who states that they are true and correct. (Petitioner) (Respondent) (Plaintiff) (Defendant) Sworn to before me this __ day of __, 19_ SIGNATURE OF ATTORNEY ATTORNEY’S NAME (PRINT OR TYPE ______________ ______________ ______________ ATTORNEY’S ADDRESS AND TELE- PHONE NUMBER |
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