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.

2 (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.(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.)

3 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.)

4 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.

5 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.)

6 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:OtherInsuranceTy pe 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)

7 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)

8 Loan paymentsUnreimbursed business expensesMiscellaneous TotalType of ExpenseDescriptionAmountOther TotalOtherTotal Expenses:5 Sunday School(l)(m)(n)(o)III. 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.)

9 (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. Long term capital gain deduction2. Depreciation, amortization or depletion3.

10 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.))