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Statement of Net Worth - jdbar.com

Revised 1/22/01 COURTCOUNTY OFIndex , against OF NET Worth (DRL 236)Date of commencement of actionComplete all items, marking "NONE," "INAPPLICABLE" AND "UNKNOWN," if appropriateSTATE OFCOUNTY OFSS.:, the (Petitioner) (Respondent) (Plaintiff) (Defendant) herein, being duly sworn,deposes and says that the following is an accurate Statement as ofof 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:, 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 of childrenAges(g) Custody of ChildrenHusbandWife(h) Minor children of prior marriage:HusbandWife(i)(paying) (receiving)(paying) (receiving) $as alimony (maintenance) and/or $child support.

Revised 1/22/01 COURT COUNTY OF Index No. Plaintiff, – against – Defendant. STATEMENT OF NET WORTH (DRL §236) Date of commencement of action Complete all items, marking "NONE," "INAPPLICABLE" AND "UNKNOWN," if appropriate

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