Net Worth Statement Form – Fill Out and Use This PDF

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	Revised 1/22/01
	COURT
COUNTY OF	Index No.

	Plaintiff,	STATEMENT OF NET WORTH
– against –		(DRL §236)


	Defendant.	Date of commencement of action
Complete all items, marking "NONE," "INAPPLICABLE" AND "UNKNOWN," if appropriate
STATE OF	COUNTY OF	SS.:
, the	(Petitioner) (Respondent) (Plaintiff) (Defendant) herein, being duly sworn,
deposes and says that the following is an accurate statement as of			,

of 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:

I.FAMILY DATA:

(a)	Husband's age		(c)	Date married
(b)	Wife's age		(d)	Date (separated) (divorced)
(e)	Number of dependent children under 21 years
(f)	Names of children	Ages

(g)

Custody of Children

Husband

Wife

Joint

(h)

Minor children of prior marriage:

Husband

Wife

(i)

Husband (paying) (receiving) $

as alimony (maintenance) and/or $

child support.

Wife

(paying) (receiving) $

as alimony (maintenance) and/or $

child support.

(j)

Custody of children of Husband's prior marriage:

Custody of children of Wife's prior marriage:

Name

Address

(k)

Is marital residence occupied by

Husband

Wife

Both

(l)Husband's present address Wife's present address

(m)Occupation of Husband Occupation of Wife

(n)Husband's employer

(o)Wife's employer

(p)Education, training and skills (Include dates of attainment of degrees, etc.) Husband

Wife

(q)Husband's health

(r)Wife's health

(s)Children's health

II.EXPENSES: (You may elect to list all expenses on a weekly basis or all expenses on a monthly basis, however, you must be consistent. If any items are paid on a monthly basis, divide by 4.3 to obtain weekly payments; if any items are paid on a weekly basis, multiply by 4.3 to obtain monthly payment. Items included under "Other" should be listed separately with separate dollar amounts.)

Expenses listed:

Weekly

Monthly

	Type of Expense	Description		Amount

(a)	Housing	Rent
		Mortgage and amortization
		Real estate taxes
		Condominium charges
		Cooperative apartment maintenance
		Other
			Housing Total

	Type of Expense	Description		Amount

(b)	Utilities	Fuel oil
		Gas
		Electricity
		Telephone
		Water
		Other
			Utilities Total

	Type of Expense	Description		Amount

(c) Food		Groceries
	Number of dependents	School lunches
	Number of dependents	Lunches at work
	including self:	Lunches at work
		Liquor/alcohol
		Home entertainment
		Other
			Food Total

	Type of Expense	Description		Amount

(d) Clothing		Husband
	Number of dependents	Wife
	Number of dependents	Children
	including self:	Children
		Other
			Clothing Total

	Type of Expense	Description		Amount

(e)	Laundry	Laundry at home
	Number of dependents	Dry cleaning
	Number of dependents	Other
	including self:	Other
			Laundry Total

	Type of Expense	Description	Amount

(f)	Insurance	Life
		Homeowner's/tenant's
		Fire, theft and liability
		Umbrella policy
		Medical plan
		Dental plan
		Optical plan
		Disability
		Workers' Compensation
		Other
		Insurance Total

	Type of Expense	Description	Amount

(g) Unreimbursed		Medical
	Medical	Dental
		Optical
		Pharmaceutical
		Surgical, nursing, hospital
		Other
		Unreimbursed Medical Total

	Type of Expense	Description	Amount

(h) Household		Repairs
	Maintenance	Furniture, furnishings, housewares
		Cleaning supplies
		Appliances, including maintenance
		Painting
		Sanitation/carting
		Gardening/landscaping
		Snow removal
		Extermination
		Other
		Household Maintenance Total

	Type of Expense	Description	Amount

(i)	Household Help	Babysitter
		Domestic (housekeeper, maid, etc.)
		Nurse
		Other
		Household Help Total

	Type of Expense	Description		Amount

(j)	Automotive	Payments
	Vehicle # 1	Gas and oil
	Vehicle # 1	Repairs
	Year:	Repairs
	Make:	Car wash
		Registration and license
	Personal:	Parking and tolls
	Business:	Insurance
		Other

		Payments
	Vehicle # 2	Gas and oil
	Vehicle # 2	Repairs
	Year:	Repairs
	Make:	Car wash
		Registration and license
	Personal:	Parking and tolls
	Business:	Insurance
		Other

			Automotive Total

	Type of Expense	Description		Amount

(k)	Educational	Nursery and pre-school
		Primary and secondary
		College
		Post-graduate
		Religious instruction
		School transportation
		School supplies/books
		Tutoring
		School events
		Other
			Educational Total

	Type of Expense	Description		Amount

(l)	Recreational	Summer camp
		Vacations
		Movies
		Theatre, ballet, etc.
		Video rentals
		Tapes, CD's, etc.
		Cable television
		Team sports
		Dining out
		Country club/pool club
		Health club
		Sporting goods
		Hobbies
	(continued on next page)	Music/dance lessons

Type of Expense	Description	Amount

(l) Recreational	Sports lessons
(Continued)	Birthday parties
	Birthday parties
	Other
	Recreational Total

Type of Expense	Description	Amount

(m) Income Taxes	Federal
	State
	City
	Social Security and Medicare
	Income Taxes Total

Type of Expense	Description	Amount

(n) Miscellaneous	Beauty parlor/barber
	Beauty aids/cosmetics, drug items
	Cigarettes/tobacco
	Books, magazines, newspapers
	Children's allowances
	Gifts
	Charitable contributions
	Religious organization dues
	Sunday School
	Diaper service
	Union and organization dues
	Commutation and transportation
	Veterinarian/pet expenses
	Child support payments (prior marriage)
	Alimony and maintenance payments (prior marriage)
	Loan payments
	Unreimbursed business expenses
	Miscellaneous Total

Type of Expense	Description	Amount

(o) Other


	Other Total
	Total Expenses:

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 affidavit .

If so, set forth name and address of all employers during preceding year and average gross weekly wage paid by each. Indicate overtime earnings separately. Attach previous year's W-2 or income tax return.)

Employer Name and Address

Average Weekly Wage

Overtime Earnings

(b) Weekly Deductions (For all employers listed in (a) above)

Amount

Federal tax

New York State tax

Local tax

Social Security

Medicare

Other payroll deductions

Annual Adjusted Income:

(d) Names of Dependents Claimed

Social Security Numbers

Enter (e) through (s) as annual amounts.

(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)Real estate (income only)

(i)Trust, profit sharing and annuities (principal distribution and income)

(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 deduction

2.Depreciation, amortization or depletion

3.Stock options - excess of fair market value over amount paid

(o) Name of Child or Other Member of Household Who is Employed

Annual Income

(p)Social Security

(q)Disability benefits

(r)Public assistance

(s)Other

Total Income:

IV. ASSETS: (If any asset is held jointly with spouse or another, so state, and set forth your respective shares.

	Type of Asset	Description		Amount

(a)	Cash	Location
	Jointly held	Location
	Jointly held	Source of funds
	Your share	Source of funds
	Other share		Cash Total

	Type of Asset	Description		Amount

(b) Checking		Financial institution
	Accounts	Address
	Account # 1	Account number
	Jointly held	Title holder
	Your share	Date opened
	Other share	Source of funds
		Balance

		Financial institution
		Address
	Account # 2	Account number
	Jointly held	Title holder
	Your share	Date opened
	Other share	Source of funds
		Balance
			Checking Accounts Total

	Type of Asset	Description		Amount

(c)	Savings	Financial institution
	Accounts	Address
	(including individual, joint,	Account number
	totten trust, certificates of	Account number
	totten trust, certificates of	Title holder
	deposit, treasury notes, etc.)	Title holder
	Account # 1	Type of account
	Jointly held	Date opened
	Your share	Source of funds
	Other share	Balance

		Financial institution
		Address
	Account # 2	Account number
		Title holder
	Jointly held	Type of account
	Your share	Date opened
	Other share	Source of funds
		Balance
			Savings Accounts Total

	Type of Asset	Description	Amount

(d)	Security Deposits,	Location
	Earnest Money, etc.	Address
	Account # 1	Title owner
	Jointly held	Type of deposit
	Your share	Source of funds
	Other share	Date of deposit
		Amount
		Security Deposits, etc. Total

	Type of Asset	Description	Amount

(e)	Other	Location
		Address
	Account # 1	Title owner
	Jointly held	Type of account
	Your share	Source of funds
	Other share	Date of deposit
		Amount
		Other Total
		Cash Accounts Total:

	Type of Asset	Description	Amount

(f)	Securities - Bonds,	Description of security
	Notes, Mortgages	Title holder
	Holding # 1	Location
	Jointly held	Address
	Your share	Date of acquisition
	Other share	Original price or value
	Maturity Date	Source of funds to acquire
		Current value
		Bonds, Notes, etc. Total

	Type of Asset	Description	Amount

(g) Stocks, Options and		Description of security
	Commodity	Title holder
	Contracts, Other	Location
		Location
	Holding # 1	Address
	Jointly held	Date of acquisition
	Your share	Original price or value
	Other share	Source of funds to acquire
		Current value
		Stocks, Options and Commodity Contracts Total
		Total Value of Securities:

	Type of Asset	Description	Amount

(h)	Brokers' Margin	Broker name
	Accounts	Address
	Account # 1	Title holder
	Jointly held	Date account opened
	Your share	Original value of account
	Other share	Source of funds
		Credit Balance
		Current value
		Brokers' Margin Accounts Total

	Type of Asset	Description	Amount

(i)	Loans to Others and	Debtor's name
	Accounts Receivable	Address
	Account # 1	Original amount of loan or debt
	Jointly held	Source of funds from which loan made or origin of debt
	Your share
	Other share	Date payment(s) due
		Current amount due

		Debtor's name
		Address
	Account # 2	Original amount of loan or debt
	Jointly held	Source of funds from which loan made or origin of debt
	Your share
	Other share	Date payment(s) due
		Current amount due
		Loans and Accounts Receivable Total

	Type of Asset	Description	Amount

(j)	Value of Interest	Business name
	In Any Business	Address
	Business # 1	Type of business (corporate, partnership, sole proprietorship or other)
	Jointly held
	Your share	Your capital contribution
	Other share	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
		Value of Business Interest Total

	Type of Asset	Description		Amount

(k)	Cash Surrender	Insurer's name
	Value of Life Ins.	Address
	Policy # 1	Name of insured
	Jointly held	Policy number
	Your share	Face amount of policy
	Other share	Policy owner
		Date of acquisition
		Source of funding to acquire
		Current cash surrender value
			Value of Life Insurance Total

	Type of Asset	Description		Amount

(l)	Vehicles (Auto, boat,	Description
	plane, truck, camper, etc.)	Title owner
		Title owner
	Vehicle # 1	Date of acquisition
	Jointly held	Original price
	Your share	Source of funds to acquire
	Other share	Amount of current lien unpaid
		Current fair market value

		Description
		Title owner
	Vehicle # 2	Date of acquisition
	Jointly held	Original price
	Your share	Source of funds to acquire
	Other share	Amount of current lien unpaid
		Current fair market value
			Value of Vehicles Total

	Type of Asset	Description		Amount

(m) Real Estate(including real		Description
	property, leaseholds, life estates,	Title owner
	etc., at market value - Do not
	etc., at market value - Do not	Date of acquisition
	deduct any mortgage)	Date of acquisition
	Property # 1	Original price
	Jointly held	Source of funds to acquire
	Your share	Amount of mortgage or lien unpaid
	Other share	Estimated current market value

		Description
		Title owner
	Property # 2	Date of acquisition
	Jointly held	Original price
	Your share	Source of funds to acquire
	Other share	Amount of mortgage or lien unpaid
		Estimated current market value
			Value of Real Estate Total

Type of Asset	Description	Amount

(n) Vested Interests in	Description of trust
Trusts (pension, profit	Location of assets
sharing, legacies, deferred	Location of assets
sharing, legacies, deferred	Address
compensation and others)	Address
Interest # 1	Title owner
Jointly held	Date of acquisition
Your share	Original investment
Other share	Source of funds
	Amount of unpaid liens
	Current value

Interest # 2	Description of trust
Jointly held	Location of assets
Your share	Address
Other share	Title owner
	Date of acquisition
	Original investment
	Source of funds
	Amount of unpaid liens
	Current value
	Vested Interest in Trusts Total

Type of Asset	Description	Amount

(o) Contingent Interests	Description
(stock options, interests	Location
subject to life estates,	Location
subject to life estates,	Address
prospective inheritances, etc.)	Address
Interest # 1	Date of vesting
Jointly held	Title owner
Your share	Date of acquisition
Other share	Original price or value
	Source of funds to acquire
	Method of valuation
	Current value
	Contingent Interests Total

Type of Asset	Description	Amount

(p) Household	Description
Furnishings	Location
Item # 1	Title owner
Jointly held	Original price
Your share	Source of funds to acquire
Other share	Amount of lien unpaid
	Current value
	Household Furnishings Total

	Type of Asset	Description	Amount

(q)	Jewelry, Art, Antiques	Description
	Precious Objects, Gold	Title owner
	and Precious Metals
	and Precious Metals	Location
	(if valued at more than $500)	Location
	Item # 1	Original price or value
	Jointly held	Source of funds to acquire
	Your share	Amount of lien unpaid
	Other share	Current value

		Description
		Title owner
	Item # 2	Location
	Jointly held	Original price or value
	Your share	Source of funds to acquire
	Other share	Amount of lien unpaid
		Current value
		Jewelry, Art, Antiques, etc. Total

	Type of Asset	Description	Amount

(r)	Other (tax shelter investments,	Description
	collections, hobbies, judgments,	Title owner
	causes of action, patents, trade-	Title owner
	marks, copyrights, and any other	Location
	asset not hereinabove itemized)
	asset not hereinabove itemized)	Original price or value
	Item # 1	Original price or value
	Jointly held	Source of funds to acquire
	Your share	Amount of lien unpaid
	Other share	Current value

		Description
		Title owner
	Item # 2	Location
	Jointly held	Original price or value
	Your share	Source of funds to acquire
	Other share	Amount of lien unpaid
		Current value
		Other Assets Total

Total Assets:

V. LIABILITIES:

Type of Liability	Description		Amount

(a) Accounts Payable	Creditor Name
	Address
Account # 1	Debtor
Jointly held	Amount of original debt
Your share	Date of incurring debt
Other share	Purpose
	Monthly or other periodic payment
	Amount of current debt
	Other relevant information

	Creditor Name
	Address
Account # 2	Debtor
Jointly held	Amount of original debt
Your share	Date of incurring debt
Other share	Purpose
	Monthly or other periodic payment
	Amount of current debt
	Other relevant information

	Creditor Name
	Address
Account # 3	Debtor
Jointly held	Amount of original debt
Your share	Date of incurring debt
Other share	Purpose
	Monthly or other periodic payment
	Amount of current debt
	Other relevant information

	Creditor Name
	Address
Account # 4	Debtor
Jointly held	Amount of original debt
Your share	Date of incurring debt
Other share	Purpose
	Monthly or other periodic payment
	Amount of current debt
	Other relevant information
		Accounts Payable Total

Type of Liability	Description	Amount

(b) Notes Payable	Name of note holder
	Address
Item # 1	Debtor
Jointly held	Amount of original debt
Your share	Date of incurring debt
Other share	Purpose
	Monthly or other periodic payment
	Amount of current debt
	Other relevant information

	Name of note holder
	Address
Item # 2	Debtor
Jointly held	Amount of original debt
Your share	Date of incurring debt
Other share	Purpose
	Monthly or other periodic payment
	Amount of current debt
	Other relevant information
	Notes Payable Total

Type of Liability	Description	Amount

(c) Installment Accounts	Creditor name
Payable	Address
(security agreements,	Debtor
chattel mortgages)	Debtor
chattel mortgages)	Amount of original debt
	Amount of original debt
Account # 1	Date of incurring debt
Jointly held	Purpose
Your share	Monthly or other periodic payment
Other share	Amount of current debt
	Other relevant information

	Creditor name
	Address
Account # 2	Debtor
Jointly held	Amount of original debt
Your share	Date of incurring debt
Other share	Purpose
	Monthly or other periodic payment
	Amount of current debt
	Other relevant information
	Installment Accounts Payable Total

	Type of Liability	Description	Amount

(d)	Brokers' Margin	Broker's Name
	Accounts	Address
	Account # 1	Amount of original debt
	Jointly held	Date of incurring debt
	Your share	Purpose
	Other share	Monthly or other periodic payment
		Amount of current debt
		Brokers' Margin Accounts Total

	Type of Liability	Description	Amount

(e)	Mortgages Payable	Mortgagee Name
	on Real Estate	Address
	Mortgage # 1	Address of property mortgaged
	Jointly held
	Your share	Mortgagor(s)
	Other share	Original debt
		Date of incurring debt
		Monthly or other periodic payment
		Maturity date
		Amount of current debt
		Current equity
		Other relevant information

		Mortgagee Name
		Address
	Mortgage # 2	Address of property mortgaged
	Jointly held
	Your share	Mortgagor(s)
	Other share	Original debt
		Date of incurring debt
		Monthly or other periodic payment
		Maturity date
		Amount of current debt
		Current equity
		Other relevant information
		Mortgages Payable Total

	Type of Liability	Description	Amount

(f)	Interest Payable	Description
	Item # 1	Amount of interest
	Jointly held	Monthly or other periodic payment
	Your share	Date due
	Other share	Other relevant information
		Interest Payable Total

	Type of Liability	Description	Amount

(g) Taxes Payable		Description of tax
	Item # 1	Amount of tax
	Jointly held	Date due
	Your share	Other relevant information
	Other share	Taxes Payable Total

	Type of Liability	Description	Amount

(h)	Loans on Life	Insurer name
	Insurance Policies	Address
		Amount of loan
	Loan # 1	Date incurred
	Jointly held	Purpose
	Your share	Borrower name
	Other share	Monthly or other periodic payment
		Amount of current debt
		Other relevant information
		Loans on Life Insurance Policies Total

	Type of Liability	Description	Amount

(i)	Other Liabilities	Description
		Creditor name
		Address
	Liability # 1	Debtor
	Jointly held	Original amount of debt
	Your share	Date incurred
	Other share	Purpose
		Monthly or other periodic payment
		Amount of current debt
		Other relevant information

	Liability # 2	Description
	Jointly held	Creditor name
	Your share	Address
	Other share	Debtor
		Original amount of debt
		Date incurred
		Purpose
		Monthly or other periodic payment
		Amount of current debt
		Other relevant information
		Other Liabilities Total
		TOTAL LIABILITIES:
		TOTAL ASSETS:
		TOTAL LIABILITIES:
		NET WORTH:
		(Assets minus Liabilities)

VI. ASSETS TRANSFERRED: (List all assets transferred in any manner during the preceding three years, or length of the marriage, whichever is shorter [transfers in the routine course of business which resulted in an exchange of assets of substantially equivalent value need not be specifically disclosed where such assets are otherwise identified in the statement of net worth]).

Description of Property

To Whom Transferred

and Relationship to

Transferee

Date of Transfer

Value

VII. SUPPORT REQUIREMENTS:

(a)

Deponent is at present(paying) (receiving)$

per (week) (month), and prior to separation

(paid) (received)$

per (week) (month) to cover expenses for:

These payments are being made(voluntarily)(pursuant to court order or judgment)(pursuant to separation agreement),

and there are(no) arrears outstanding (in the sum of $

to date).

(b)

Deponent requests for support of each child $

per (week) (month).

Total for child(ren)

(c)

Deponent requests for support of self $

per (week) (month).

(d)

The day of the(week) (month) on which payment should be made is

VIII. COUNSEL FEE REQUIREMENTS:

(a)

Deponent requests for counsel fee and disbursements the sum of

(b)

Deponent has paid counsel the sum of $

and has agreed with counsel concerning fees as follows:

(c)There is (not) a retainer agreement or written agreement relating to payment of legal fees. (A copy of any such agreement must be annexed.)

(c)Deponent requires the services of an accountant for the following reasons:

(d)Deponent requires the services of an appraiser for the following reasons:

X.Other data concerning the financial circumstances of the parties that should be brought to the attention of the Court are:

The foregoing statements and a rider consisting of page(s) annexed hereto and made part hereof, have been

carefully read by the undersigned, who state that they are true and correct.

(Petitioner)(Respondent)

(Plaintiff)(Defendant)

Sworn to before me this

day of	,

	NOTARY PUBLIC

CERTIFICATION OF ATTORNEY

I hereby certify under penalty of perjury and as an officer of the court that I have no knowledge that the substance of any of the factual submissions contained in this document is false.

Date	(Signature of Attorney)

Attorney's Name (Print or Type)

Attorney's Address & Telephone Number

Question	Answer
Form Name	Net Worth Statement Form
Form Length	18 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	4 min 30 sec
Other names	how to fill out statement of net worth new york, statement of net worth new york pdf, networth statement forms, ny statement of net worth fillable form

IX. ACCOUNTANT AND APPRAISAL FEES REQUIREMENTS:

Deponent requests for accountants' fees and disbursements the sum of $

(Include basis for fee, e.g., hourly rate, flat rate.)

Deponent requests for appraisal fees and disbursements the sum of $

(Include basis for fee, e.g., hourly rate, flat rate.)