New York State Financial Disclosure Affidavit

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)

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 )

COUNTY OF ) ss.:

I, , the Petitioner Respondent 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:

I. INCOME FROM ALL SOURCES

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 $

g. Driver's, professional, recreational, sporting and other licenses and permits held

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. Check applicable box:

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). Additional cost to include 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 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:

d. 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

V. VARIANCE FROM THE PERCENTAGES

The following is/are the factor(s) that the Court should consider in this case:

VI. EXPENSES

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

a) Rent or mortgage payment $

b) Mortgage interest and amortization $

c) Realty taxes $

d) Insurance on realty $

e) Utilities: gas electric water telephone cable

f) Garbage collection $

g) Household repairs $

h) Food $

i) Charge accounts, loans, etc. $

$

$

j) Auto expense: gas maintenance insurance & fees loan

k) Public transportation $

l) Life insurance $

m) Health insurance $

n) Clothing: self $ others $

Explain:

o) Laundry and dry cleaning $

p) Education and tuition $

q) Child care $

r) Contributions $

s) Union dues yes No $

t) Entertainment $

u) Miscellaneous personal expenses $

v) Other $

w) TOTAL weekly Monthly Expenses $

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. [Notarization of your signature is REQUIRED].

Attorney's Address and Telephone Number

ADDENDUM A - CHILD SUPPORT PERCENTAGES

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, 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 twenty-five dollars ($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 fifty dollars ($50) per month or the difference 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 finds that the non-custodial parent's pro-rata share of the basic child support obligation is unjust or inappropriate. Factors include financial resources, health of the child, standard of living, tax consequences, non-monetary contributions, educational needs, income disparity, needs of other children, visitation expenses, and any other relevant factors.