F.C.A. §§413-1, 424-a; Art. 5-B Form 4-17
D.R.L. §§236-B, 240 (Financial Disclosure Afdavit)
10/2012
FAMILY COURT OF THE STATE OF NEW YORK
COUNTY OF
.............................................................................................
In the Matter of a Proceeding for Support Docket No.
(Commissioner of Social Services, Assignor,
on behalf of , Assignee)
FINANCIAL
Petitioner DISCLOSURE
AFFIDAVIT
-against-
Respondent.
.............................................................................................
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 fled 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 fle tax
returns, a copy of your W-2 form for the most recent
year for which you fled 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 benefts 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 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 defned 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 ( Weekly Bi-weekly Monthly Semi–monthly
Annual)
$________
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 fled Federal and State income tax returns, including all
schedules): ________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
c. Interest/Dividend Income :
________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
d. Other Income/ Benefts:
1 Unless ordered confdential, 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.
1. Workers Compensation 1. $________ per __________
2. Disability Benefts 2. $________ per __________
3. Unemployment Insurance Benefts 3. $________ per __________
4. Social Security Benefts 4. $________ per __________
5. Veterans Benefts 5. $________ per __________
6. Pensions and Retirement Benefts 6. $________ per __________
7. Fellowships/Stipends/Annuities 7. $________ per __________
8. Supplemental Security Income (SSI) 8. $________ per __________
9. Public Assistance 9. $________ per __________
10. Food Stamps 10. $________ per __________
e. Income from other sources : (List here and explain any other income including but
not limited to: non-income producing assets; employment “perks” and reimbursed
expenses to the extent that they reduce personal expenses; fringe benefts 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. Unreimbursed employee business expenses a. $_______________
b. Maintenance actually paid to spouse not a party to this action* b. $_______________
c. Maintenance actually paid to spouse who is a party to this action c. $_______________
d. Child support actually paid on behalf of non- subject child(ren)* d. $_______________
e. Public Assistance and Food Stamps e. $_______________
f. Supplemental Security Income f. $_______________
g. NYC/Yonkers Income Tax g. $_______________
h. Social Security/Medicare Taxes h. $_______________
*Attach to this form a copy of the appropriate Court Order
IV. HEALTH INSURANCE, UNREIMBURSED HEALTH-RELATED EXPENSES, CHILD
CARE EXPENSES, EDUCATIONAL EXPENSES AND LIFE AND ACCIDENT
INSURANCE POLICIES :
As part of the child support obligation, parents must be directed to provide health
insurance coverage, pay a pro-rated share of the cost or premiums to obtain or
maintain the health insurance coverage, a pro-rated share of unreimbursed health-
related expenses, pro-rated share of child care expenses and, in the Court's discretion,
educational expenses. The Court may direct you to purchase and maintain life and/or
accident insurance benefts or assign benefts on existing policies for the beneft of
your children. List your information as follows and cross out or delete inapplicable
provisions:
a. [Check applicable box]:
I do NOT have health insurance coverage [If this box is checked, SKIP to
section IV(b), below]
I HAVE health insurance coverage through [specify]:
Employer or organization Private purchase Medicaid
Child Health Plus program; my monthly premium is $ ____________
1. My coverage includes medical dental prescription drugs optical
other health care services or benefts [specify]:
_______________________________________
2. The cost of the insurance paid by me is $______________per _______________
3. The person(s) covered by my insurance is/are:
___________________________________________
________________________________________________________________________________
4. My policy number is .
5. Coverage does does not presently include my child(ren). The additional
cost to me to include my child(ren) would be [specify cost for each type of
beneft; if beneft unavailable, so indicate]:
Medical: $____________ per _______ Optical: $____________ per _______
Dental: $____________ per _______ Prescription drugs: $____________ per _______
Other Health Services or Benefts [specify]:___________________ $____________ per
_______
6. The name and address of my primary (and secondary) health insurer is/are:
___________________
_______________________________________________________________________________
7. My primary (and secondary) health plan administrator is/are: (indicate name,
address and telephone number of contact person for employer or
organization): __________________________________
_______________________________________________________________________________
8. There are medical dental prescription drugs optical
other health care benefts [specify]: ______________________________ benefts
available to the child(ren) through an individual who is not a party to this
action. This individual is [indicate name and relationship]:
_________________________________________________________________.
The cost is: $____________ per _______.
b. My child care provider is:
_______________________________________________________________
The average number of hours of child care incurred per week are:
_______________________________
c. My child's educational needs and expenses are:
______________________________________________
____________________________________________________________________________________
I have the following life and accident insurance policies:
1. Life insurance : (Name of insurer):____________________________
$______________
(Beneficiary/Beneficiaries):_____________________________________
(Name of insurer):____________________________ $______________
(Beneficiary/Beneficiaries):_____________________________________
2. Accident insurance : (Name of insurer):____________________________ $______________
(Name of insurer):____________________________ $______________
This information is current as of (specify date) __________________________.
V. VARIANCE FROM THE PERCENTAGES: The Family Court Act allows the Court to order support
different from the percentages if the Court finds that the support based upon the percentages would be unjust
or inappropriate due to certain factors. The factors are set forth in Addendum D . The following is/are the
factor(s) that the Court should consider in this case: _____________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
VI. EXPENSES: In ordering support by the percentages the Court is not obligated to consider your expenses.
However, if the Court varies from the percentages, your expenses may be considered. List your expenses as
follows: List all expenses on a weekly or monthly basis; however, you must be consistent.
If any items are paid monthly, divide by 4.3 to obtain the weekly payment. If any items are paid weekly,
multiply by 4.3 to obtain the monthly payment .
Check applicable box : I am listing my expenses on a weekly monthly basis:
EXPENSE ITEM COST [check box]:
weekly monthly
a) Rent or mortgage payment a. $
b) Mortgage interest and amortization b. $
c) Realty taxes(if not included in mortgage payment) c. $
d) Insurance on realty d. $
e) Utilities: gas electric water telephone
cable e. $
f) Garbage collection f. $
g) Household repairs (specify) g. $
h) Food h. $
i) Charge accounts, loans, etc. (from Section VII below) i. $
1)
2)
3)
j) Auto expense: gas maintenance insurance &
fees j. $
loan
k) Public transportation k. $
l) Life insurance l. $
m) Health insurance m. $
n) Clothing: self $ others $ n. $
(Explain:
)
o) Laundry and dry cleaning o. $
p) Education and tuition (explain:
) p. $
q) Child care q. $
r) Contributions r. $
s) Union dues (Are dues mandatory? yes No)
s. $
t) Entertainment
t. $
u) Miscellaneous personal expenses (specify:
) u. $
v) Other (specify:
) v. $
w) TOTAL: weekly Monthly Expenses w. $
VII. LIABILITIES, LOANS AND DEBTS : In ordering support by the percentages the
Court is not obligated to consider liabilities, loans, and debts. However, if the Court
varies from the percentages, they may be considered. List your liabilities, loans and
debts as follows:
Creditor ____________________ Creditor ____________________ Creditor ____________________
Purpose _________________ Purpose _________________ Purpose _________________
Date incurred _____________ Date incurred _____________ Date incurred _____________
Total balance due $_________ Total balance due $_________ Total balance due $_________
Monthly payment $ _________ Monthly payment $ _________ Monthly
payment $ ________
NOTE: ATTACH TO THIS FORM INFORMATION REGARDING ANY ADDITIONAL DEBTS.
I have carefully read the foregoing statement and attest to its truth and accuracy.
[ Notarization of your signature is REQUIRED].
_________________________________________
(Petitioner)(Respondent)
_________________________________________
Print or Type Name
_________________________________________
Signature of Attorney, if any
_________________________________________
Attorney's Name (Print or Type)
_________________________________________
_________________________________________
_________________________________________
Attorney's Address and Telephone
Number
Sworn to before me this __________
day of ______________, _________.
______________________________
Notary Public
(Deputy)Clerk of the Court
ADDENDUM A
CHILD SUPPORT PERCENTAGES
The child support percentages that shall be applied by the Court unless the Court makes a
fnding that the non-custodial parentss share is unjust or inappropriate are as follows: 17t for one
child; 25t for two children; 29t for three children; 31t for four children; and no less than 35t for
fve or more children.
ADDENDUM B
COMBINED PARENTAL INCOME “CAP”
Where combined parental income exceeds the amount published by the New York State OTDA
pursuant to Social Services Law 111-i(2)a, the Court shall determine the amount of child support for
the amount of the combined parental income in excess of such dollar amount through consideration
of the factors set forth in Addendum D and/or the support percentage set forth in Addendum A. The
combined parental income amount will be revised every two years, beginning on January 31, 2012,
and the revised amount will be posted on-line at www.newyorkchildsupport.com .
ADDENDUM C
SELF-SUPPORT RESERVE
Where the annual amount of the basic child support obligation would reduce the non-custodial
parentss income below the poverty income guidelines amount for a single person as reported by the
federal Department of Health and Human Services, the basic child support obligation shall be
twenty-fve dollars ($25) per month unless the interests of justice dictate otherwise. Where the
annual amount of the basic child support obligation would reduce the non-custodial parent's income
below the self-support reserve but not below the poverty income guidelines amount of a single
person as reported by the federal Department of Health and Human Services, the basic child
support obligation shall be ffty dollars ($50) per month or the diference between the non-custodial
parent's income and the self-support reserve, whichever is greater.
ADDENDUM D
VARIANCE FROM THE PERCENTAGES
The Court has the discretion to vary from the percentages if it fnds that the non-custodial
parent's pro-rata share of the basic child support obligation is unjust or inappropriate. This fnding
shall be based upon consideration of the following factors:
1. The fnancial resources of the custodial and non-custodial parent, and those of the child.
2. The physical and emotional health of the child and his/her special needs and aptitudes.
3. The standard of living the child would have enjoyed had the marriage or household not been
dissolved.
4. The tax consequences to the parties.
5. The non-monetary contributions that the parents will make toward the care and well-being of the
child.
6. The educational needs of either parent.
7. A determination that the gross income of one parent is substantially less than the other parent's
gross income.
8. The needs of the children of the non-custodial parent for whom the non-custodial parent is
providing support who are not subject to the instant action and whose support has not been
deducted from income, and the fnancial resources of any person obligated to support such
children, provided, however, that this factor may apply only if the resources available to support
such children are less than the resources available to support the children who are subject to the
instant action.
9. Provided that the child is not on public assistance (i) extraordinary expenses incurred by the
non-custodial parent in exercising visitation, or (ii) expenses incurred by the non-custodial
parent in extended visitation provided that the custodial parent's expenses are substantially
reduced as a result thereof.
10. Any other factors the Court determines are relevant in each case.
NOTE: The language in the above Addenda is paraphrased from the statute for the purposes of
simplifcation. For statutory language, see Family Court Act Sections 413(1), 416 and 424-a and
Domestic Relations Law Sections 236-B and 240.
