Financial Disclosure Form

Financial Disclosure Affidavit

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)

Petitioner

FINANCIAL 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 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. INCOME FROM ALL SOURCES:

I, , the herein, residing at , 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:

a. Wages and Salaries

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

b. Federal Income Tax

c. New York State Tax

d. NYC/Yonkers Tax

e. Other payroll deductions

5. Number of members in household

6. Number of dependents

7. Income of other members of household per

per

b. Self-Employment Income

c. Interest/Dividend Income

d. Other Income/Benefits

1. Workers Compensation per

2. Disability Benefits per

3. Unemployment Insurance Benefits per

4. Social Security Benefits per

5. Veterans Benefits per

6. Pensions and Retirement Benefits per

7. Fellowships/Stipends/Annuities per

8. Supplemental Security Income (SSI) per

9. Public Assistance per

10. Food Stamps per

e. Income from other sources

II. ASSETS:

a. Savings account balance (Name of bank: )

b. Checking account balance (Name of bank: )

c. Automobile(s) (Year and make: )

Loan information

d. Residence owned (Address: )

e. Other real estate owned

f. Other assets

III. DEDUCTIONS FROM INCOME:

a. Unreimbursed employee business expenses

b. Maintenance actually paid to spouse not a party to this action

c. Maintenance actually paid to spouse who is a party to this action

d. Child support actually paid on behalf of non-subject child(ren)

e. Public Assistance and Food Stamps

f. Supplemental Security Income

g. NYC/Yonkers Income Tax

h. Social Security/Medicare Taxes

IV. HEALTH INSURANCE, UNREIMBURSED HEALTH-RELATED EXPENSES, CHILD CARE EXPENSES, EDUCATIONAL EXPENSES AND LIFE AND ACCIDENT INSURANCE POLICIES:

a. I do NOT have health insurance coverage

I HAVE health insurance coverage through

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 benefits

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).

Medical: $ per Optical: $ per

Dental: $ per Prescription drugs: $ per

Other Health Services or Benefits $ 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:

8. There are medical dental prescription drugs optical other health care benefits available to the child(ren) through an individual who is not a party to this action.

This individual is . 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:

VI. EXPENSES:

Check applicable box: I am listing my expenses on a weekly monthly basis:

VII. LIABILITIES, LOANS AND DEBTS:

Creditor Purpose Date incurred Total balance due Monthly payment

Creditor Purpose Date incurred Total balance due Monthly payment

Creditor Purpose Date incurred Total balance due Monthly payment

I have carefully read the foregoing statement and attest to its truth and accuracy.

ADDENDUM A - CHILD SUPPORT PERCENTAGES

The child support percentages that shall be applied by the Court unless the Court makes a finding that the non-custodial parent’s share is unjust or inappropriate are as follows: 17% for one child; 25% for two children; 29% for three children; 31% for four children; and no less than 35% for five 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.

ADDENDUM C - SELF-SUPPORT RESERVE

Where the annual amount of the basic child support obligation would reduce the non-custodial parent's income below the poverty income guidelines amount for a single person, the basic child support obligation shall be $25 per month unless the interests of justice dictate otherwise. Where the annual amount would reduce income below the self-support reserve but not below the poverty income guidelines amount, the basic child support obligation shall be $50 per month or the difference between income and the self-support reserve, whichever is greater.

ADDENDUM D - VARIANCE FROM THE PERCENTAGES

1. The financial 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 financial 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 simplification. For statutory language, see Family Court Act Sections 413(1), 416 and 424-a and Domestic Relations Law Sections 236-B and 240.