Statement of Net Worth - jdbar.com

1 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.

2 (j)Custody of children of Husband's prior marriage:NameAddress(k) Is marital residence occupied by HusbandWifeBoth(l)Husband's present addressWife's present address(m) Occupation of HusbandOccupation of Wife(n) Husband's employer(o) Wife's employer(p) Education, training and skills (Include dates of attainment of degrees, etc.)HusbandWife(q) Husband's health(r)Wife's health(s) Children's healthHusbandWifechild support.$as alimony (maintenance) and/or $Custody of children of Wife's prior marriage:JointII. EXPENSES: (You may elect to list all expenses on a weekly basis or all expenses on a monthly basis, however, you mustbe consistent. If any items are paid on a monthly basis, divide by to obtain weekly payments; if any items are paid on aweekly basis, multiply by to obtain monthly payment. Items included under "Other" should be listed separately with separate dollar amounts.)Expenses listed:WeeklyMonthlyType of ExpenseDescriptionAmountUtilities TotalUtilitiesFuel oilGasElectricityTelephoneWaterOtherType of ExpenseDescriptionAmountFood TotalFoodGroceriesSchool lunchesLunches at workLiquor/alcoholHome entertainmentOtherNumber of dependentsincluding self:Type of ExpenseDescriptionAmountHousing TotalHousingRentMortgage and amortizationReal estate taxesCondominium chargesCooperative apartment maintenanceOtherType of ExpenseDescriptionAmountClothing TotalClothingHusbandWifeChildrenOtherNum ber of dependentsincluding self:Type of ExpenseDescriptionAmountLaundry TotalLaundryLaundry at homeDry cleaningOtherNumber of dependentsincluding self.

3 2(a)(b)(c)(d)(e)Type of ExpenseDescriptionAmountInsurance TotalInsuranceLifeHomeowner's/tenant'sFi re, theft and liabilityUmbrella policyMedical planOtherDental planOptical planDisabilityWorkers' CompensationType of ExpenseDescriptionAmountUnreimbursed Medical TotalUnreimbursed MedicalDentalOpticalPharmaceuticalSurgic al, nursing, hospitalOtherMedicalType of ExpenseDescriptionAmountHousehold Maintenance TotalHouseholdRepairsFurniture, furnishings, housewaresCleaning suppliesAppliances, including maintenancePaintingOtherSanitation/carti ngGardening/landscapingSnow removalExterminationMaintenanceType of ExpenseDescriptionAmountHousehold Help TotalHousehold HelpBabysitterDomestic (housekeeper, maid, etc.)Other3 Nurse(f)(g)(h)(i)Type of ExpenseDescriptionAmountAutomotive TotalAutomotivePaymentsGas and oilRepairsCar washRegistration and licenseGas and oilVehicle #Year:Parking and tollsOtherPaymentsMake:Personal:Business :RepairsCar washRegistration and licenseParking and tollsInsuranceYear:Vehicle #Make:Personal:Business.

4 OtherInsuranceType of ExpenseDescriptionAmountEducational TotalEducationalNursery and pre-schoolPrimary and secondaryCollegePost-graduateReligious instructionOtherSchool transportationSchool supplies/booksTutoringSchool eventsType of ExpenseDescriptionAmountRecreationalSumm er campVacationsMoviesTheatre, ballet, rentalsTapes, CD's, televisionTeam sportsDining outCountry club/pool clubHealth clubSporting goodsHobbiesMusic/dance lessons(continued on next page)4(j)(k)(l)12 Type of ExpenseDescriptionAmountRecreational TotalRecreationalSports lessonsBirthday partiesOther(Continued)Type of ExpenseDescriptionAmountIncome Taxes TotalIncome TaxesFederalStateSocial Security and MedicareCityType of ExpenseDescriptionAmountMiscellaneousBea uty parlor/barberBeauty aids/cosmetics, drug itemsCigarettes/tobaccoBooks, magazines, newspapersChildren's allowancesGiftsCharitable contributionsReligious organization duesDiaper serviceUnion and organization duesCommutation and transportationVeterinarian/pet expensesChild support payments (prior marriage)Alimony and maintenance payments (prior marriage)Loan paymentsUnreimbursed business expensesMiscellaneous TotalType of ExpenseDescriptionAmountOther TotalOtherTotal Expenses:5 Sunday School(l)(m)(n)(o)III.

5 GROSS INCOME: (State source of income and annual amount)(a) Salary or wages: (State whether income has changed during the year preceding date of this so, set forth name and address of all employers during preceding year and average gross weekly wage paid by overtime earnings separately. Attach previous year's W-2 or income tax return.)Employer Name and AddressAverage Weekly WageOvertime Earnings(b) AmountFederal taxNew York State taxLocal taxSocial SecurityMedicareOther payroll deductions(c) Social Security number(d) Social Security Numbers(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)Trust, profit sharing and annuities (principal distribution and income)(i)Real estate (income only)(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.

6 Long term capital gain deduction2. Depreciation, amortization or depletion3. Stock options - excess of fair market value over amount paid(o) Annual Income(p) Social Security(q) Disability benefits(r)Public assistance(s) OtherTotal Income:6 Weekly Deductions (For all employers listed in (a) above)Names of Dependents ClaimedName of Child or Other Member of Household Who is EmployedAnnual Adjusted Income:Enter (e) through (s) as annual of AssetDescriptionAmountCash TotalCash LocationSource of fundsIV. ASSETS: (If any asset is held jointly with spouse or another, so state, and set forth your respective shares. Type of AssetDescriptionAmountChecking Accounts TotalChecking Financial institutionAddressAccount numberTitle holderDate openedSource of fundsBalanceAccountsAccount #Financial institutionAddressAccount numberTitle holderDate openedSource of fundsBalanceDescriptionAmountType of AssetDescriptionAmountSavings Accounts TotalSavingsFinancial institutionAddressAccount numberTitle holderDate openedSource of fundsBalanceAccountsAccountsAccount #Financial institutionAddressAccount numberTitle holderDate openedSource of fundsBalance(including individual, joint,totten trust, certificates ofdeposit, treasury notes, etc.))

7 Account #Account #Type of accountType of account7 Jointly heldYour shareOther shareJointly heldYour shareOther shareJointly heldYour shareOther shareYour shareOther shareJointly heldJointly heldYour shareOther share(a)(b)(c)1212 Type of AssetDescriptionAmountSecurity Deposits,LocationAddressTitle ownerType of depositSource of fundsDate of depositAmountEarnest Money, #Jointly heldYour shareOther shareSecurity Deposits, etc. TotalType of AssetDescriptionAmountOtherLocationAddre ssTitle ownerType of accountSource of fundsDate of depositAmountAccount #Jointly heldYour shareOther shareOther TotalCash Accounts Total:Type of AssetDescriptionAmountSecurities - Bonds,Description of securityTitle holderLocationAddressDate of acquisitionOriginal price or valueSource of funds to acquireNotes, MortgagesHolding #Jointly heldYour shareOther shareBonds, Notes, etc. TotalCurrent value8 Type of AssetDescriptionAmountStocks, Options andDescription of securityTitle holderLocationAddressDate of acquisitionOriginal price or valueSource of funds to acquireCommodity Holding #Jointly heldYour shareOther shareStocks, Options and Commodity Contracts TotalCurrent valueContracts, OtherMaturity DateTotal Value of Securities.

8 (d)(e)(f)(g)1111 Type of AssetDescriptionAmountBrokers' MarginBroker nameAddressTitle holderDate account openedOriginal value of accountSource of fundsCurrent valueAccountsAccount #Jointly heldYour shareOther shareBrokers' Margin Accounts TotalType of AssetDescriptionAmountLoans and Accounts Receivable TotalLoans to Others andDebtor's nameAddressOriginal amount of loan or debtSource of funds from which loan made or origin of debtDate payment(s) dueCurrent amount dueAccounts ReceivableAccount #Debtor's nameAddressOriginal amount of loan or debtSource of funds from which loan made or origin of debtDate payment(s) dueCurrent amount dueAccount #Jointly heldYour shareOther shareJointly heldYour shareOther shareType of AssetDescriptionAmountValue of InterestBusiness nameAddressType of business (corporate, partnership, sole proprietorship or other)Your capital contributionYour percentage of interestDate of acquisitionOriginal price or valueSource of funds to acquireMethod of valuationOther relevant informationCurrent net Worth of businessValue of Business Interest TotalIn Any BusinessBusiness #Jointly heldYour shareOther share9 Credit Balance(h)(i)(j)1121 Type of AssetDescriptionAmountValue of Vehicles TotalVehicles DescriptionTitle ownerDate of acquisitionOriginal priceSource of funds to acquireAmount of current lien unpaidCurrent fair market valueplane, truck, camper, etc.

9 Vehicle #DescriptionTitle ownerDate of acquisitionOriginal priceSource of funds to acquireAmount of current lien unpaidCurrent fair market valueVehicle #Jointly heldYour shareOther shareJointly heldYour shareOther shareType of AssetDescriptionAmountCash Surrender Insurer's nameAddressName of insuredPolicy numberFace amount of policyPolicy ownerDate of acquisitionValue of Life #Jointly heldYour shareOther shareValue of Life Insurance Total(Auto, boat,Source of funding to acquireCurrent cash surrender valueType of AssetDescriptionAmountValue of Real Estate TotalReal EstateDescriptionTitle ownerDate of acquisitionOriginal priceSource of funds to acquireAmount of mortgage or lien unpaidEstimated current market valueproperty, leaseholds, life estates,Property #DescriptionTitle ownerDate of acquisitionOriginal priceSource of funds to acquireAmount of mortgage or lien unpaidEstimated current market valueProperty #Jointly heldYour shareOther shareJointly heldYour shareOther share(including realetc.))

10 , at market value - Do notdeduct any mortgage)10(k)(l)(m)11212 Type of AssetDescriptionAmountVested Interest in Trusts TotalVested Interests in Description of trustLocation of assetsTitle ownerDate of acquisitionOriginal investmentSource of fundsAmount of unpaid liensTrustsInterest #Description of trustLocation of assetsTitle ownerDate of acquisitionOriginal investmentSource of fundsAmount of unpaid liensInterest #Jointly heldYour shareOther shareJointly heldYour shareOther sharesharing, legacies, deferred compensation and others)(pension, profit Current valueCurrent valueAddressAddressType of AssetDescriptionAmountContingent InterestsDescriptionLocationAddressDate of vestingTitle ownerDate of acquisitionOriginal price or value(stock options, interestsInterest #Jointly heldYour shareOther shareContingent Interests TotalSource of funds to acquireMethod of valuationsubject to life estates,prospective inheritances, etc.)Current valueType of AssetDescriptionAmountHouseholdDescripti onLocationTitle ownerOriginal priceSource of funds to acquireAmount of lien unpaidCurrent valueFurnishingsItem #Jointly heldYour shareOther shareHousehold Furnishings Total11(n)(o)(p)1211 Type of AssetDescriptionAmountJewelry, Art, Antiques, etc.