Husband's Age:
Wife's Age:
Names and Date of Birth for each child of marriage
Name:
Date of Birth:
1:
2:
3:
Who has custody (if applicable, attach copy of order):
Amount of alimony and/or child support received for prior children:
Is marital residence occupied by:
Husband's or Spouse's Current Address
Name:
Street Address:
City:
State:
Country:
Zip Code:
Email Id:
Occupation of
Husband:
Wife:
Education or training or skills (include date of degrees)
Husband:
Wife:
Employer of
Husband:
Wife:
Health of
Husband:
Wife:
Children:
EXPENSES
Housing
Rent :
Mortgage :
Real estate taxes:
Condominium charges:
Cooperative apartment maintenance:
Utilities
Fuel oil:
Gas:
Electricity:
Telephone:
Water:
Food:
Groceries:
School lunches:
Lunches at Work:
Dining Out:
Liquor/Alcohol:
Home entertainment:
Other:
Clothing
Husband:
Wife:
Children:
Other:
Laundry
Laundry at Home:
Dry Cleaning:
Other:
Insurance
Life:
Homeowner/tenant:
Fire, theft and liability:
Auto:
Umbrella:
Dental:
Optical:
Disabiity:
Worker's Comp:
Other:
Unreimbursed Medical/Health
Medical:
Dental:
Optical:
Prescription:
Surgical, nursing, hospital:
Other:
Household Maintenance
Repairs:
Furniture:
Cleaning Suppies:
Appliances, inc. maintenance:
Painting:
Sanitation:
Gardening/landscaping:
Snow removal:
Extermination:
Other:
Household Help
Babysitter:
Domestic:
Other:
Automotive
Year:
Make:
Year:
Make:
Year:
Make:
Payments:
Gas and oil:
Repairs:
Car wash:
Registration and license:
Parking and tolls:
Other:
Educational
Nursery and preschool:
Primary and secondary:
College:
Post graduate:
Religious instruction:
School transportation:
School supplies/books:
Tutoring:
School events:
Other:
Recreational
Summer camp:
Vacations:
Movies:
Theatre, ballet, etc.:
DVD/Video rentals:
Tapes, CD's, etc.:
Cable television:
Team sports:
Country club/pool:
Health club:
Sporting goods:
Hobbies:
Music/dance lessons:
Sports lessons:
Birthday parties:
Other:
Income taxes
Federal:
State:
City:
Medicare and Social Security:
Other:
TOTAL EXPENSES:
INCOME
Salary or wages: Attach previous year's W-2 and one month of paystubs
Weekly deductions
Federal tax:
New York State tax:
Local tax:
Social Security:
Medicare:
Other payroll deductions:
Social Security Number:
Number of Dependents Claimed:
Bonus, commissions, fringe benefits:
Partnership, royalties and sale of assets:
Dividends and interest:
Real estate (income only):
Trust, profit sharing and annuities:
Pension (income only):
Awards, prizes, grants:
Bequests, legacies and gifts:
Income from all other sources:
Tax preference items
Long term capital gain deduction:
Depreciation, amortization or depletion:
Stock options:
If any child or other member of your household is employed
Employer:
Income:
Social Security:
Disability:
Public Assistance:
Other:
ASSETS
Cash Accounts
Cash
Source of Funds:
Amount:
Checking Account
1. Bank:
Account Number:
Date Opened:
Source of Funds:
Balance:
2. Bank:
Account Number:
Date Opened:
Source of Funds:
Balance:
Savings Account (joint, individual, CD's, etc.)
1. Bank:
Account Number:
Date Opened:
Source of Funds:
Balance:
2. Bank:
Account Number:
Date Opened:
Source of Funds:
Balance:
Security Deposits, earnest money, etc.
Bank:
Account Number:
Date Opened:
Source of Funds:
Balance:
Other
Bank:
Account Number:
Date Opened:
Source of Funds:
Balance:
Securities
Bonds, notes, mortgages, etc.
Description of Security:
Title Holder:
Date of Acquisition:
Original Price or value:
Source of Funds to Acquire:
Current Value:
Stocks, options and commodity contracts
1. Description of Security:
Title Holder:
Date of Acquisition:
Original Price or value:
Source of Funds to Acquire:
Current Value:
2. Description of Security:
Title Holder:
Date of Acquisition:
Original Price or value:
Source of Funds to Acquire:
Current Value:
3. Description of Security:
Title Holder:
Date of Acquisition:
Original Price or value:
Source of Funds to Acquire:
Current Value:
Broker Margin Accounts
Description of Security:
Title Holder:
Date of Acquisition:
Original Price or value:
Source of Funds to Acquire:
Current Value:
Loans to others and accounts payable
1. Debtor's name and address:
Original amount of loan or debt:
Date payment due:
Current Amount Due:
2. Debtor's name and address:
Original amount of loan or debt:
Date payment due:
Current Amount Due:
Value of interest in business
Name and address of business:
Type of business:
Your capital contribution:
Your percentage of interest:
Date of acquisition:
Original price or value:
Source of funds to acquire:
Method of valuation:
Other relevant information:
Current net worth of business:
Cash surrender value of life insurance
Insurer's name and address:
Name of insured:
Policy Number:
Face amount of policy:
Policy owner:
Date of acquisition:
Source of funding:
Current cash surrender value:
Vehicles (boat, plane, truck, camper, etc.)
1. Type:
Title owner:
Date of acquisition:
Original Price:
Source of funds to acquire:
Amount of current lien unpaid:
Current value:
2. Type:
Title owner:
Date of acquisition:
Original Price:
Source of funds to acquire:
Amount of current lien unpaid:
Current value:
Real Estate
1. Description:
Title owner:
Date of acquisition:
Original Price:
Source of funds to acquire:
Amount of mortgage or
Estimated current market value:
2. Description:
Title owner:
Date of acquisition:
Original Price:
Source of funds to acquire:
Amount of mortgage or
Estimated current market value:
Vested interests in trusts (pension, profit sharing, legacies, deferred comp plans, etc.)
1. Description of trust:
Location of assets:
Title owner:
Date of acquisition:
Original Investment:
Source of funds:
Amount of lien unpaid:
Current market value:
2. Description of trust:
Location of assets:
Title owner:
Date of acquisition:
Original Investment:
Source of funds:
Amount of lien unpaid:
Current market value:
Contingent Interests (stock options, etc.)
Description of trust:
Location of assets:
Title owner:
Date of vesting:
Date of acquisition:
Original Price or value:
Source of funds to acquire:
Method of valuation:
Current market value:
Household Furnishings
1. Description:
Location:
Title owner:
Original price:
Source of funds to acquire:
Amount of lien unpaid:
Current value:
2. Description:
Location:
Title owner:
Original price:
Source of funds to acquire:
Amount of lien unpaid:
Current value:
Jewelry, art, antiques, gold or other precious metals
1. Description:
Location:
Title owner:
Original price:
Source of funds to acquire:
Amount of lien unpaid:
Current value:
2. Description:
Location:
Title owner:
Original price:
Source of funds to acquire:
Amount of lien unpaid:
Current value:
Other
1. Description:
Location:
Title owner:
Original price:
Source of funds to acquire:
Amount of lien unpaid:
Current value:
2. Description:
Location:
Title owner:
Original price:
Source of funds to acquire:
Amount of lien unpaid:
Current value:
LIABILITIES
Accounts Payable/Notes Payable/Installment Accounts
1. Name and address of creditor:
Debtor:
Amount of original debt:
Date of incurring debt:
Purpose:
Monthly:
Amount of current debt:
2. Name and address of creditor:
Debtor:
Amount of original debt:
Date of incurring debt:
Purpose:
Monthly:
Amount of current debt:
3. Name and address of creditor:
Debtor:
Amount of original debt:
Date of incurring debt:
Purpose:
Monthly:
Amount of current debt:
Brokers margins accounts
Name and address of creditor:
Debtor:
Amount of original debt:
Date of incurring debt:
Purpose:
Monthly:
Amount of current debt:
Mortgages on real estate
1. Name and address of mortgagee:
Address of property:
Mortgagor:
Amount of original debt:
Date of incurring debt:
Monthly or periodic payment:
Maturity Date:
Amount of current debt:
2. Name and address of mortgagee:
Address of property:
Mortgagor:
Amount of original debt:
Date of incurring debt:
Monthly or periodic payment:
Maturity Date:
Amount of current debt:
Taxes Payable
Description of tax:
Amount of tax:
Date due:
Loans on life insurance policies
Name and address of insurer:
Amount of loan:
Date of incurred:
Purpose:
Monthly or periodic payment:
Name of Borrower:
Amount of current debt:
Other Liabilities
1. Description:
Name and address of creditor:
Debtor:
Original amount of debt:
2. Description:
Name and address of creditor:
Debtor:
Original amount of debt:
SUPPORT REQUIREMENTS (provide copy of order)
Child Support:
Amount:
If Court Ordered, which court:
Verification Code:
