Statement Net Worth Form – Fill Out and Use This PDF

The Statement of Net Worth form is a detailed financial disclosure document required in divorce proceedings in many jurisdictions, including New York under DRL §236. It necessitates individuals to provide a comprehensive account of their income, expenses, assets, and liabilities, ensuring a transparent overview of their financial situation. This thorough documentation is utilized to determine equitable distribution of assets, spousal support, and child support. To initiate the completion process for your Statement of Net Worth, please click the button below.

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Statement Net Worth Form PDF Details

At the core of financial disclosures during divorce proceedings lies the Statement of Net Worth Form, an intricate document designed to meticulously outline an individual's financial standing. Revised in November 1998, this form serves as a comprehensive affidavit in divorce actions, specifically mandated under the Domestic Relations Law Section 236. It requires the disaggregation of assets versus liabilities, detailing income from various sources, and cataloging assets transferred. Essential to both parties involved, the form encapsulates a broad range of financial information, including, but not limited to, personal data related to family dynamics such as dependent children, custody arrangements, educational background, and health status of family members. The document extends to envelop an enumeration of living expenses, broken down into categories such as housing, utilities, food, and education, amongst others, allowing parties to present a detailed account of weekly or monthly expenditures. Further, it delves into the realms of gross income and assets, capturing salaries, bonuses, dividends, and interests, along with meticulous details of checking and savings accounts, securities, and real estate holdings. Designed to furnish a court with a transparent view of the financial landscape within which decisions on alimony, child support, and asset division will be made, the Statement of Net Worth is a pivotal document in ensuring equitable resolutions in divorce proceedings.

Question	Answer
Form Name	Statement Net Worth Form
Form Length	14 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min 30 sec
Other names	drl 236, stament of net worth, form statement net worth, net worth statement new york

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	REVISED 11/98
COURT
COUNTY OF	Index No.
______________________________________________
Plaintiff,	STATEMENT OF
- against -	NET WORTH
	(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 ____________

(b)Wife's age _______________

(c)Date married _____________

(d)Date (separated)(divorced) ___________________

(e)Number of dependent children under 21 years _________________

(f)Names and ages of children

_______________________________________

(g)Custody of Children _____Husband _____Wife

(h)Minor children of prior marriage: _____Husband _____Wife

(i)(Husband)(Wife) (paying)(receiving) $_______ as alimony (maintenance) and/or $_______ child support in connection with prior marriage

(j)Custody of children of 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. Attach additional sheet, if needed. Items included under "Other" should be listed separately with separate dollar amounts.)

	Expenses listed [] weekly		[] monthly
(a)	Housing
1.	Rent	_______	4.	Condominium charges	_______
2.	Mortgage and		5.	Cooperative apartment
	amortization	_______		maintenance	_______
3.	Real estate taxes	_______
				Total: Housing

$_________

(b)Utilities

1.	Fuel oil	_______	4.	Telephone		_______
2.	Gas	_______	5.	Water		_______
3.	Electricity	_______
				Total:	Utilities
$_________
(c)	Food
1.	Groceries	_______	5.	Liquor/alcohol		_______
2.	School lunches	_______	6.	Home entertainment		_______
3.	Lunches at work	_______	7.	Other ____________		_______
4.	Dining Out	_______
				Total:	Food
$_________

(d)Clothing

1.	Husband	_______	3.	Children		_______
2.	Wife	_______	4.	Other __________		_______
				Total:	Clothing
$_________
(e)	Laundry
1.	Laundry at home	_______	3.	Other __________		_______
2.	Dry cleaning	_______
				Total:	Laundry
$_________

(f)Insurance

1.	Life	_______	6.	Medical plan		_______
2.	Homeowner's/tenant's_______		7.	Dental plan		_______
3.	Fire, theft and		8.	Optical plan		_______
	liability	_______	9.	Disability		_______
4.	Automotive	_______	10.		Worker's Compensation _______
5.	Umbrella policy	_______	11.		Other __________	_______
					Total: Insurance

$_________

(g)Unreimbursed medical

1.	Medical	_______	5.	Surgical, nursing,
2.	Dental	_______		hospital	_______
3.	Optical	_______	6.	Other __________	_______
4.	Pharmaceutical	_______

Total: Unreimbursed medical

$_________

(h)Household maintenance

1.	Repairs	_______	5.	Painting	______
2.	Furniture, furnishings		6.	Sanitation/carting	______
	housewares	_______	7.	Gardening/landscaping	______
3.	Cleaning supplies	_______	8.	Snow removal	______
4.	Appliances, including		9.	Extermination	______
	maintenance	_______	10. Other __________		______

Total: Household maintenance

$________

(i)Household help

1.	Babysitter	_______	3. Other __________	_______
2.	Domestic (housekeeper, maid, etc.) ________

Total: Household help

$_________

(j)Automotive

Year:_______	Make:___________________	Personal: ___ Business: ___
Year:_______	Make:___________________	Personal: ___	Business: ___
Year:_______	Make:___________________	Personal: ___	Business: ___

1.	Payments		_______	4.	Car wash		_______
2.	Gas and	oil	_______	5.	Registration and license_______
3.	Repairs		_______	6.	Parking and tolls		_______
			7. Other _______
					Total:	Automotive

$_________

(k)Educational

1.	Nursery and pre-school	______	6.	School transportation	_______
2.	Primary and secondary	______	7.	School supplies/books	_______
3.	College	______	8.	Tutoring	_______
4.	Post-graduate	______	9.	School events	_______
5.	Religious instruction	______	10. Other _________		_______
				Total: Educational

$_________

(l)Recreational

1.	Summer camp	______	9. Country club/pool club			_______
2.	Vacations	______	10.	Health club		_______
3.	Movies	______	11.	Sporting goods		_______
4.	Theatre, ballet, etc.	______	12.	Hobbies		_______
5.	Video rentals	______	13.	Music/dance lessons		_______
6.	Tapes, CD's, etc.	______	14.	Sports lessons		_______
7.	Cable television	______	15.	Birthday parties		_______
8.	Team sports	______	16.	Other ____________		_______
				Total:	Recreational
$_________
(m)	Income taxes
1.	Federal	______	3. City			_______
2.	State	______	4. Social Security and			_______
				Medicare
				Total:	Income taxes
$_________

(n)Miscellaneous

1.	Beauty parlor/barber	______	9. Union and organi-
2.	Beauty aids/cosmetics,			zation dues
_______
	drug items	______	10. Commutation and
				transportation	_______
3.	Cigarettes/tobacco	_______	11.	Veterinarian/pet expenses______
4.	Books, magazines,		12.	Child support payments
	newspapers	_______		(prior marriage)	_______
5.	Children's allowances	_______	13.	Alimony and maintenance payments
6.	Gifts	_______		(prior marriage)	_______
7.	Charitable contributions______		14.	Loan payments	_______
8.	Religious organization		15.	Unreimbursed business

dues	_______	expenses	_______
		Total:	Miscellaneous
$_________

(o)Other

1.	_______________	_______	3.	_________________	_______
2.	_______________	_______	4.	_________________	_______
				Total: Other

$_________

TOTAL EXPENSES: $_________________

III.GROSS INCOME: (State source of income and annual amount. Attach addi- tional sheet, if needed).

(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 weekly wage paid by each. Indicate overtime earnings separately. Attach previous year's W-2 or income tax return.)

_____________________________________________

(b)Weekly deductions:

1.	Federal tax	_______
2.	New York State tax	_______
3.	Local tax	_______
4.	Social Security	_______
5.	Medicare	_______
6.	Other payroll deductions (specify)	_______

(c)Social Security number ______________

(d)Number and names of dependents claimed: ______________________

(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)	If any	child or other member of your household
	is employed, set forth name and that person's
	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.	Attach additional sheets, if

needed.)

A.Cash Accounts Cash

1.1a. Location____________________________________

b.Source of funds_____________________________

c.Amount______________________________________ $______

Total: Cash

$______

Checking Accounts

2.1a. Financial institution ______________________

b.Account number _____________________________

c.Title holder _______________________________

d.Date opened_________________________________

e.Source of Funds_____________________________

f.Balance_____________________________________ $_________

2.2a. Financial institution

______________________

b. Account number _____________________________

c. Title Holder _______________________________

d.Date opened_________________________________

e.Source of Funds_____________________________

f.Balance_____________________________________ $_________

Total: Checking

$______

Savings accounts (including individual, joint, totten trust, certificates of deposit, treasury notes)

3.1a. Financial institution ______________________

b.Account number _____________________________

c.Title holder _______________________________

d.Type of account_____________________________

e.Date opened_________________________________

f.Source of funds_____________________________

g.Balance_____________________________________ $_________

3.2a. Financial institution ______________________

b.Account number _____________________________

c.Title holder _______________________________

d.Type of account_____________________________

e.Date opened_________________________________

f.Source of funds_____________________________

g.Balance_____________________________________ $_________

Total: Savings

$_________

Security deposits, earnest money, etc.

4.1a. Location ___________________________________

b.Title owner ________________________________

c.Type of deposit ____________________________

e.Source of funds_____________________________

f.Date of deposit ____________________________

g. Amount______________________________________ $_________

Total: Security Deposits, etc.

$_________

Other

5.1 a. Location ___________________________________

b. Title owner ________________________________

c. Type of account ____________________________

d.Source of funds_____________________________

e.Date of deposit ____________________________

f.Amount______________________________________ $_________

Total: Other

$_________

Total: Cash Accounts

$_________

B.Securities

Bonds, notes, mortgages

1.1a. Description of security ____________________

b.Title holder _______________________________

c.Location ___________________________________

d.Date of acquisition ________________________

e.Original price or value ____________________

f.Source of funds to acquire _________________

g. Current value_______________________________ $_________

Total: Bonds, notes, etc.

$_________

Stocks, options and commodity contracts

2.1a. Description of security _____________________

b.Title holder ________________________________

c.Location ____________________________________

d.Date of acquisition _________________________

e.Original price or value _____________________

f.Source of funds to acquire __________________

g. Current value________________________________

$_________

2.2a. Description of security _____________________

b.Title holder ________________________________

c.Location ____________________________________

d.Date of acquisition _________________________

e.Original price or value _____________________

f.Source of funds to acquire __________________

g. Current value________________________________

$_________

2.3a. Description of security _____________________

b. Title holder

________________________________

c.Location ____________________________________

d.Date of acquisition _________________________

e.Original price or value _____________________

f.Source of funds to acquire __________________

g. Current value________________________________ $_________

Total: Stocks, options, etc.

$________

Broker margin accounts

3.1a. Name and address of broker___________________

b.Title holder_________________________________

c.Date account opened _________________________

d.Original value of account ___________________

e.Source of funds _____________________________

f. Current value________________________________ $_________

Total: Margin accounts

$_________

Total value of securities:

$_________

C.Loans to others and accounts receivable

1.1a. Debtor's name and address ______________________

b.Original amount of loan or debt ________________

c.Source of funds from which loan made or origin of debt ________________________________________

d.Date payment(s) due_____________________________

e. Current amount due______________________________

$_________

1.2a. Debtor's name and address_______________________

b.Original amount of loan or debt ________________

c.Source of funds from which loan made or origin of debt ________________________________________

d.Date payment(s) due_____________________________

e. Current amount due______________________________ $_________

Total: Loans and accounts receivable $_______

D.Value of interest in any business

1.1a. Name and address of business ___________________

b.Type of business (corporate, partnership, sole proprietorship or other)________________________

c.Your capital contribution ______________________

d.Your percentage of interest _____________________

e.Date of acquisition _____________________________

f.Original price or value _________________________

g.Source of funds to acquire ______________________

h.Method of valuation _____________________________

i.Other relevant information_______________________

j.Current net worth of business ___________________ $__________

Total: Value of business interest

$_______

E.Cash surrender value of life insurance

1.1a. Insurer's name and address ______________________

b.Name of insured _________________________________

c.Policy number ___________________________________

d.Face amount of policy ___________________________

e.Policy owner ____________________________________

f.Date of acquisition _____________________________

g.Source of funding to acquire_____________________

h.Current cash surrender value ____________________ $__________

Total: Value of life insurance

$_______

F.Vehicles (automobile, boat, plane, truck, camper, etc.)

1.1a. Description _____________________________________

b.Title owner _____________________________________

c.Date of acquisition _____________________________

d.Original price __________________________________

e.Source of funds to acquire_______________________

f.Amount of current lien unpaid ___________________

g.Current fair market value _______________________ $__________

1.2a. Description _____________________________________

b.Title owner _____________________________________

c.Date of acquisition _____________________________

	8.
d. Original price __________________________________
e. Source of funds to acquire ______________________
f. Amount of current lien unpaid ___________________
g. Current fair market value _______________________	$__________
Total: Value of Vehicles	$_______

G.Real estate (including real property, leaseholds, life estates, etc. at market value -- do not deduct any mortgage)

1.1a. Description _____________________________________

b.Title owner _____________________________________

c.Date of acquisition _____________________________

d.Original price __________________________________

e.Source of funds to acquire ______________________

f.Amount of mortgage or lien unpaid _______________

g.Estimated current market value __________________ $__________

1.2a. Description _____________________________________

b.Title owner _____________________________________

c.Date of acquisition _____________________________

d.Original price __________________________________

e.Source of funds to acquire ______________________

f.Amount of mortgage or lien unpaid _______________

g.Estimated current market value __________________ $__________

1.3a. Description _____________________________________

b.Title owner _____________________________________

c.Date of acquisition _____________________________

d.Original price __________________________________

e.Source of funds to acquire ______________________

f.Amount of mortgage or lien unpaid _______________

g.Estimated current market value __________________ $__________

Total: Value of real estate

$_________

H. Vested interests in trusts (pension, profit sharing, legacies, deferred compensation

and others)

1.1a. Description of trust ____________________________

b.Location of assets ______________________________

c.Title owner _____________________________________

d.Date of acquisition _____________________________

e.Original investment _____________________________

f.Source of funds _________________________________

g.Amount of unpaid liens __________________________

h.Current value ___________________________________ $__________

1.2a. Description of trust ____________________________

b.Location of assets ______________________________

c.Title owner _____________________________________

d.Date of acquisition _____________________________

e.Original investment _____________________________

f.Source of funds _________________________________

g.Amount of unpaid liens __________________________

h.Current value ___________________________________ $__________

Total: Vested interest in trusts

$_________

I.Contingent interests (stock options, interests subject to life estates, prospective

inheritances, etc.)

1.1a. Description ______________________________________

b.Location _________________________________________

c.Date of vesting __________________________________

d.Title owner ______________________________________

e.Date of acquisition ______________________________

f.Original price or value __________________________

g.Source of funds to acquire _______________________

h.Method of valuation ______________________________

i.Current value ____________________________________ $__________

Total: Contingent interests

$_________

J.Household furnishings

1.1a. Description ______________________________________

b.Location _________________________________________

c.Title owner ______________________________________

d.Original price ___________________________________

e.Source of funds to acquire _______________________

f.Amount of lien unpaid ____________________________

g.Current value ____________________________________ $__________

Total: Household furnishings

$_______

K.Jewelry, art, antiques, precious objects, gold and precious metals (only if

valued

at more than $500)

1.1a. Description ______________________________________

b.Title owner ______________________________________

c.Location _________________________________________

d.Original price or value __________________________

e.Source of funds to acquire _______________________

f.Amount of lien unpaid ____________________________

g.Current value ____________________________________ $__________

1.2a. Description ______________________________________

b.Title owner ______________________________________

c.Location _________________________________________

d.Original price or value __________________________

e.Source of funds to acquire _______________________

f.Amount of lien unpaid ____________________________

g.Current value ____________________________________ $__________

Total: Jewelry, art, etc.:

$_______

L.Other (e.g., tax shelter investments, collections, judgments, causes of action, patents, trademarks, copyrights, and any other asset not hereinabove itemized)

1.1a. Description ______________________________________

b.Title owner ______________________________________

c.Location _________________________________________

d.Original price or value __________________________

e.Source of funds to acquire _______________________

f.Amount of lien unpaid ____________________________

g.Current value ____________________________________ $_______

1.2a. Description ______________________________________

b.Title owner ______________________________________

c.Location _________________________________________

d.Original price or value __________________________

10.

e. Source of funds to acquire _______________________

f. Amount of lien unpaid ____________________________

g. Current value ____________________________________ $_______

		Total: Other
$_________
		TOTAL: ASSETS	$_______________
V.	LIABILITIES
A.	Accounts payable
	1.1 a.	Name and address of
creditor______________________
	b. Debtor____________________________________________
	c. Amount of original debt __________________________
	d. Date of incurring debt ___________________________
	e. Purpose __________________________________________
	f. Monthly or other periodic payment ________________
	g. Amount of current debt____________________________		$_______
	1.2 a.	Name and address of
creditor______________________
	b. Debtor____________________________________________
	c. Amount of original debt __________________________
	d. Date of incurring debt ___________________________
	e. Purpose __________________________________________
	f. Monthly or other periodic payment ________________
	g. Amount of current debt____________________________		$_______
	1.3 a.	Name and address of
creditor______________________
	b. Debtor____________________________________________
	c. Amount of original debt __________________________
	d. Date of incurring debt ___________________________
	e. Purpose __________________________________________
	f. Monthly or other periodic payment ________________
	g. Amount of current debt____________________________		$_______
	1.4 a.	Name and address of
creditor______________________
	b. Debtor____________________________________________
	c. Amount of original debt __________________________
	d. Date of incurring debt ___________________________
	e. Purpose __________________________________________
	f. Monthly or other periodic payment ________________
	g. Amount of current debt____________________________		$_______
	1.5 a.	Name and address of
creditor______________________
	b. Debtor____________________________________________
	c. Amount of original debt __________________________
	d. Date of incurring debt ___________________________
	e. Purpose __________________________________________
	f. Monthly or other periodic payment ________________
	g. Amount of current debt____________________________		$_______

Total: Accounts payable

$_________

11.

B.Notes payable

1.1a. Name and address of note holder___________________

b.Debtor____________________________________________

c.Amount of original debt __________________________

d.Date of incurring debt ___________________________

e.Purpose __________________________________________

f.Monthly or other periodic payment_________________

g.Amount of current debt____________________________ $_______

1.2a. Name and address of note holder__________________

b.Debtor___________________________________________

c.Amount of original debt _________________________

d.Date of incurring debt __________________________

e.Purpose _________________________________________

f.Monthly or other periodic payment _______________

g.Amount of current debt___________________________ $_______

Total: Notes payable

$_________

C.Installment accounts payable (security agreements, chattel mortgages)

1.1a. Name and address of creditor _____________________

b.Debtor____________________________________________

c.Amount of original debt __________________________

d.Date of incurring debt ___________________________

e.Purpose __________________________________________

f.Monthly or other periodic payment_________________

g.Amount of current debt____________________________ $_______

1.2a. Name and address of creditor ______________________

b.Debtor___________________________________________

c.Amount of original debt _________________________

d.Date of incurring debt __________________________

e.Purpose _________________________________________

f. Monthly or other periodic payment _______________

g. Amount of current debt___________________________ $_______

Total: Installment accounts

$_________

D.Brokers' margin accounts

1.1a. Name and address of broker ______________________

b.Amount of original debt _________________________

c.Date of incurring debt __________________________

d.Purpose _________________________________________

e.Monthly or other periodic payment________________

f.Amount of current debt___________________________ $_______

Total: Brokers' margin accounts

$_________

E.Mortgages payable on real estate

1.1a. Name and address of mortgagee ____________________

b.Address of property mortgaged ____________________

c.Mortgagor(s) _____________________________________

d.Original debt ____________________________________

e.Date of incurring debt ___________________________

f.Monthly or other periodic payment ________________

g.Maturity Date ____________________________________

h.Amount of current debt____________________________ $_______

1.2a. Name and address of mortgagee ____________________

b.Address of property mortgaged ____________________

12.

c. Mortgagor(s) _____________________________________

d. Original debt ____________________________________

e. Date of incurring debt ___________________________

f. Monthly or other periodic payment ________________

g. Maturity date ____________________________________

h.Amount of current debt____________________________ $_______

Total: Mortgages payable

$_________

F.Taxes payable

1.1a. Description of tax _______________________________

b.Amount of tax ____________________________________

c.Date due _________________________________________

Total: Taxes payable

$_________

G.Loans on life insurance policies

1.1a. Name and address of insurer ______________________

b.Amount of loan ___________________________________

c.Date incurred ____________________________________

d.Purpose __________________________________________

e.Name of borrower _________________________________

f.Monthly or other periodic payment ________________

g.Amount of current debt ___________________________ $_______

Total: Life insurance loans

$_________

H.Other liabilities

1.1a. Description ______________________________________

b.Name and address of creditor _____________________

c.Debtor ___________________________________________

d.Original amount of debt __________________________

e.Date incurred ____________________________________

f.Purpose __________________________________________

g.Monthly or other periodic payment ________________

h.Amount of current debt ___________________________ $______

1.2a. Description ______________________________________

b.Name and address of creditor _____________________

c.Debtor ___________________________________________

d.Original amount of debt __________________________

e.Date incurred ____________________________________

f.Purpose __________________________________________

g.Monthly or other periodic payment ________________

h.Amount of current debt ___________________________ $______

Total: Other liabilities

$_________
	TOTAL LIABILITIES:		$______________
	NET WORTH
TOTAL ASSETS:		$____________
TOTAL LIABILITIES:	(minus)	($____________)
NET WORTH:		$____________

13.

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]).

	To Whom Transferred
Description	and Relationship to	Date of
of Property	Transferee	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 children $__________.

(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 pay- ment of legal fees. (A copy of any such agreement must be annexed.)

IX.	ACCOUNTANT AND APPRAISAL FEES REQUIREMENTS:

(a)Deponent requests for accountants' fees and disbursements the sum of $_______. (Include basis for fee, e.g., hourly rate, flat rate)

(b)Deponent requests for appraisal fees and disbursements the sum of

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

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

_____________________________________________________________________________

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

_____________________________________________________________________________

14.

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 states that
they are	true and correct.
		_______________________________________
		(Petitioner)	(Respondent)
		(Plaintiff)	(Defendant)
Sworn to	before me this
day of		, 19

_______________________

_______________________________________

SIGNATURE OF ATTORNEY

_______________________________________

ATTORNEY'S NAME (PRINT OR TYPE)

_______________________________________

ATTORNEY'S ADDRESS & TELEPHONE NUMBER

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