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[UCS Rev. 6/2016 eff. 8/1/16 (8/12/16 version)] Page 1
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF
---------------------------------------------------------------------X
Plaintiff, STATEMENT
OF NET WORTH
DATED:
- against -
Index No.
Date Action Commenced:
Defendant.
----------------------------------------------------------------------X
Complete all items, marking “NONE”, “INAPPLICABLE” and “UNKNOWN”, if appropriate
STATE OF NEW YORK )
)ss.:
COUNTY OF )
_______________________, the Plaintiff/Defendant herein, being duly sworn, deposes
and says that, subject to the penalties of perjury, 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 and statement of expenses:
I. FAMILY DATA
(a) Plaintiff’s date of birth:
(b) Defendant’s date of birth:
(c) Date married:
(d) Names and dates of birth of Child(ren) of the
marriage:
(e) Minor child(ren) of prior marriage:
(f) Custody of child(ren) of prior marriage:
(g) Plaintiff’s present address:
Defendant’s present address:
(h) Occupation/Employer of Plaintiff:
Occupation/Employer of Defendant:
1
2
NOTE: If there is any additional information that cannot fit on this form please use rider
on the last page.
_______________________
Names
Date of Birth
use rider for additional child(ren)
Fillable PDF Form
[UCS Rev. 6/2016 eff. 8/1/16 (8/12/16 version)] Page 2
II. EXPENSES: (List your current expenses on a monthly basis. If there has been any
change in these expenses during the recent past please indicate). Items included under
“other” should be listed separately with separate dollar amounts.)
(a)
Housing: Monthly
1. Mortgage/Co-op Loan
2. Home Equity Line of Credit/Second Mortgage
3. Real Estate Taxes
(if not included in mortgage payment)
4. Homeowners/Renter’s Insurance
5. Homeowner’s Association/Maintenance
charges/Condominium Charges
6. Rent
7. Other
TOTAL: HOUSING
(b)
Utilities: Monthly
1. Fuel Oil/Gas
2. Electric
3. Telephone (land line)
4. Mobile Phone
5. Cable/Satellite TV
6. Internet
7. Alarm
8. Water
9. Other
TOTAL: UTILITIES
$0.00
$0.00
[UCS Rev. 6/2016 eff. 8/1/16 (8/12/16 version)] Page 3
(c)
Food: Monthly
1. Groceries
2. Dining Out/Take Out
3. Other
TOTAL: FOOD
(d)
Clothing: Monthly
1. Yourself
2. Child(ren)
3. Dry Cleaning
4. Other
TOTAL: CLOTHING
(e)
Insurance: Monthly
1. Life
2. Fire, theft and liability and personal articles policy
3. Automotive
4. Umbrella Policy
5. Medical Plan
5A. Medical Plan for yourself (Including name of
carrier and name of insured)
5B. Medical Plan for children (Including name of
carrier and name of insured)
6. Dental Plan
7. Optical Plan
8. Disability
$0.00
$0.00
[UCS Rev. 6/2016 eff. 8/1/16 (8/12/16 version)] Page 4
9. Worker’s Compensation
10. Long Term Care Insurance
11. Other
TOTAL: INSURANCE
(f)
Unreimbursed Medical: Monthly
1. Medical
2. Dental
3. Optical
4. Pharmaceutical
5. Surgical, Nursing, Hospital
6. Psychotherapy
7. Other
TOTAL: UNREIMBURSED MEDICAL
(g)
Household Maintenance: Monthly
1. Repairs/Maintenance
2. Gardening/landscaping
3. Sanitation/carting
4. Snow Removal
5. Extermination
6. Other
TOTAL: HOUSEHOLD MAINTENANCE
(h)
Household Help: Monthly
1. Domestic (housekeeper, etc.)
2. Nanny/Au Pair/Child Care
3. Babysitter
4. Other
TOTAL: HOUSEHOLD HELP
$0.00
$0.00
$0.00
$0.00
[UCS Rev. 6/2016 eff. 8/1/16 (8/12/16 version)] Page 5
(i)
Automobile: Monthly
(List data for each car separately)
Year:______ Make:________ Personal
:_____
Business:_____
1.
Lease or Loan Payments (indicate lease term)
2. Gas and Oil
3. Repairs
4. Car Wash
5. Parking and tolls
6. Other
TOTAL: AUTOMOTIVE
(j)
Education Costs: Monthly
1. Nursery and Pre-school
2. Primary and Secondary
3. College
4. Post-Graduate
5. Religious Instruction
6. School Transportation
7. School Supplies/Books
8. School Lunches
9. Tutoring
10. School Events
11. Child(ren)’s extra-curricular and educational
enrichment activities (Dance, Music, Sports, etc.)
12. Other
TOTAL: EDUCATION
(k)
Recreational: Monthly
1. Vacations
2. Movies, Theatre, Ballet, Etc.
- or -
mos
$0.00
$0.00
[UCS Rev. 6/2016 eff. 8/1/16 (8/12/16 version)] Page 6
3. Music (Digital or Physical Media)
4. Recreation Clubs and Memberships
5. Activities for yourself
6. Health Club
7. Summer Camp
8. Birthday party costs for your child(ren)
9. Other
TOTAL: RECREATIONAL
(l)
Income Taxes: Monthly
1. Federal
2. State
3. City
4. Social Security and Medicare
5. Number of dependents claimed in prior tax year
6.
List any refund received by you for prior tax year
TOTAL: INCOME TAXES
(m)
Miscellaneous: Monthly
1. Beauty parlor/Barber/Spa
2. Toiletries/Non-Prescription Drugs
3. Books, magazines, newspapers
4. Gifts to others
5. Charitable contributions
6. Religious organizations dues
7. Union and organization dues
8. Commutation expenses
9. Veterinarian/pet expenses
$0.00
$0.00
[UCS Rev. 6/2016 eff. 8/1/16 (8/12/16 version)] Page 7
10. Child support payments (for Child(ren) of a prior
marriage or relationship pursuant to court order or
agreement)
11. Alimony and maintenance payments (prior marriage
pursuant to court order or agreement)
12. Loan payments
13. Unreimbursed business expenses
14. Safe Deposit Box rental fee
TOTAL: MISCELLANEOUS
(n)
Other: Monthly
1.
2.
3.
TOTAL: OTHER
TOTAL: MONTHLY EXPENSES
$0.00
$0.00
$0.00
[UCS Rev. 6/2016 eff. 8/1/16 (8/12/16 version)] Page 8
III.
GROSS INCOME INFORMATION:
(a) Gross (total) income - as should have been or should be reported in
the most recent Federal income tax return.
(State whether your income has changed during the year
preceding date of this affidavit. If so, please explain.)
Attach most recent W-2, 1099s, K1s and income tax returns.
List any amount deducted from gross income for retirement
benefits or tax deferred savings.
(b) To the extent not already included in gross income in (a) above:
1. Investment income, including interest and
dividend income, reduced by sums expended
in connection with such investment
2. Worker’s compensation (indicate percentage of
amount due to lost wages)
3. Disability benefits (indicate percentage of
amount due to lost wages)
4. Unemployment insurance benefits
5. Social Security benefits
6. Supplemental Security Income
7. Public assistance
8. Food stamps
9. Veterans benefits
10. Pensions and retirement benefits
11. Fellowships and stipends
12. Annuity payments
(c) If any child or other member of your household is employed, set
forth name and that person’s annual income:
(d) List any maintenance and/or child support you are receiving
pursuant to court order or agreement
(e) Other:
%
%
[UCS Rev. 6/2016 eff. 8/1/16 (8/12/16 version)] Page 9
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. 1. Cash Accounts:
Cash
1.1 a. Location
b. Source of Funds
c. Amount as of date of commencement
d. Current amount
TOTAL: CASH
2. Checking Accounts:
2.1 a. Financial Institution
b. Account Number
c. Title holder
d. Date opened
e. Source of Funds
f. Balance as of date of commencement
g. Current balance
2.2 a. Financial Institution
b. Account Number
c. Title holder
d. Date opened
e. Source of Funds
f. Balance as of date of commencement
g. Current balance
TOTAL: Checking Accounts
[UCS Rev. 6/2016 eff. 8/1/16 (8/12/16 version)] Page 10
3. Savings Account (including individual, joint, totten
trust, certificates of deposit, treasury notes)
3.1 a. Financial Institution
b. Account Number
c. Title holder
d. Type of account
e. Date opened
f. Source of Funds
g. Balance as of date of commencement
h. Current balance
3.2 a. Financial Institution
b. Account Number
c. Title holder
d. Type of account
e. Date opened
f. Source of Funds
g. Balance as of date of commencement
h. Current balance
TOTAL: Savings Accounts
TOTAL: Accounts $
B. 4. Real Estate (Including real property, leaseholds, life
estates, etc. at market value – do not deduct any
mortgage)
4.1 a. Description
b. Title owner
c. Date of acquisition
d. Original price
[UCS Rev. 6/2016 eff. 8/1/16 (8/12/16 version)] Page 11
e. Source of funds to acquire
f. Amount of mortgage or lien unpaid
g. Estimate current fair market value
4.2 a. 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. Estimate current fair market value
TOTAL: Real Estate
C. 5. Retirement Accounts (e.g. IRAs, 401(k)s, 403(b)s,
pension, profit sharing plans, deferred compensation
plans, etc.)
5.1 a. Description
b. Location of assets
c. Title owner
d. Date of acquisition
e. Source of funds
f. Amount of unpaid liens
g. Value as of date of commencement
h. Current value
5.2 a. Description
b. Location of assets
c. Title owner
d. Date of acquisition
e. Source of funds
[UCS Rev. 6/2016 eff. 8/1/16 (8/12/16 version)] Page 12
f. Amount of unpaid liens
g. Value as of date of commencement
h. Current value
TOTAL: Retirement Accounts
D. 6. Vehicles (Auto, Boat, Truck, Plane, Camper,
Motorcycles, etc.)
6.1 a. Description
b. Title owner
c. Date of acquisition
d. Original price
e. Source of funds to acquire
f. Amount of lien unpaid
g. Current fair market value
h. Value as of date of commencement
6.2 a. Description
b. Title owner
c. Date of acquisition
d. Original price
e. Source of funds to acquire
f. Amount of lien unpaid
g. Current fair market value
h. Value as of date of commencement
TOTAL: Value of Vehicles $
E. 7. Jewelry, art, antiques, household furnishings, precious
objects, gold and precious metals (only if valued at
more than $500)
7.1 a. Description
b. Title owner
[UCS Rev. 6/2016 eff. 8/1/16 (8/12/16 version)] Page 13
c. Location
d. Original price or value
e. Source of funds to acquire
f. Amount of lien unpaid
g. Value as of date of commencement
h. Estimate Current Value
7.2 a. Description
b. Title Owner
c. Location
d. Original price or value
e. Source of funds to acquire
f. Amount of lien unpaid
g. Value as of date of commencement
h. Estimate Current Value
TOTAL Value of Jewelry, Art, Antiques, etc. $
IF YOU HAVE NO OTHER ASSETS OR
BUSINESS INTERESTS, GO TO THE
LIABILITIES SECTION ON PAGE 17
F. 8. Interest in any Business
8.1 a. Name and Address of Business
b. Type of Business (corporate, partnership, sole
proprietorship or other)
c. Your percentage of interest
d. Date of acquisition
e. Original price or value
%
[UCS Rev. 6/2016 eff. 8/1/16 (8/12/16 version)] Page 14
f. Source of funds to acquire
g. Net worth of business and date of such
valuation
h. Other relevant information
TOTAL: Value of Business Interests
G. 9. Cash Surrender Value of Life Insurance
9.1 a. 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 funds
h. Cash surrender value as of date of
commencement
i. Current cash surrender value
9.2 a. 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 funds
h. Cash surrender value as of date of
commencement
i. Current cash surrender value
Total: Cash Surrender Value of Life Insurance
as of
$
[UCS Rev. 6/2016 eff. 8/1/16 (8/12/16 version)] Page 15
H. 10. Investment Accounts/Securities/Stock
Options/Commodities/Broker Margin Accounts
10.1 a. Description
b. Title holder
c. Location
d. Date of acquisition
e. Source of funds
f. Value as of date of commencement
g. Current value
10.2 a. Description
b. Title holder
c. Location
d. Date of acquisition
e. Source of funds
f. Value as of date of commencement
g. Current Value
TOTAL: Investment Accounts/Securities/Stock
Options/Commodities/Broker Margin Accounts
TOTAL: Value of Securities $
I. 11. Loans to Others and Accounts Receivable
11.1 a. 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. Amount due as of date of commencement
f. Current amount due
TOTAL: Loans to Others and Accounts Receivable
[UCS Rev. 6/2016 eff. 8/1/16 (8/12/16 version)] Page 16
J. 12. Contingent Interests (stock options, interests subject to
life estates, prospective inheritances)
12.1 a. Description
b. Location
c. Date of vesting
d. Title owner
e. Date of acquisition
f. Original price or value
g. Source of acquisition to acquire
h. Method of valuation
i. Value as of date of commencement
j. Current value $
TOTAL: Contingent Interests $
K. 13. Other Assets (e.g., tax shelter investments, collections,
judgments, causes of action, patents, trademarks,
copyrights, and any other asset not hereinabove
itemized)
13.1 a. Description
b. Title owner
c. Location
d. Original Price or value
e. Source of funds to acquire
f. Amount of lien unpaid
g. Value as of date of commencement
h. Current value
TOTAL: Other Assets $
TOTAL ASSETS: $
[UCS Rev. 6/2016 eff. 8/1/16 (8/12/16 version)] Page 17
V.
LIABILITIES
A. 1. 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 debt as of date of commencement
h. 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 debt as of date of commencement
h. Amount of current debt
TOTAL: Accounts Payable $
B. Credit Card Debt
2. 2.1 a. Debtor
b. Amount of original debt
c. Date of incurring debt
d. Purpose
e. Monthly or other periodic payment
f. Amount of debt as of date of commencement
g. Amount of current debt
[UCS Rev. 6/2016 eff. 8/1/16 (8/12/16 version)] Page 18
2.2 a. Debtor
b. Amount of original debt
c. Date of incurring debt
d. Purpose
e. Monthly or other periodic payment
f. Amount of debt as of date of commencement $
g. Amount of current debt $
TOTAL: Credit Card Debt $
C. 3. Mortgages Payable on Real Estate
3.1 a. 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 debt as of date of commencement
i. Amount of current debt
3.2 a. 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
[UCS Rev. 6/2016 eff. 8/1/16 (8/12/16 version)] Page 19
h. Amount of debt as of date of commencement
i. Amount of current debt
TOTAL: Mortgages Payable
D. 4. Home Equity and Other Lines of Credit
4.1 a. 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 debt at date of commencement
i. Amount of current debt
TOTAL: Home Equity and Other Lines of Credit $
E. 5. Notes Payable
5.1 a. Name and address of noteholder
b. Debtor
c. Amount of original debt
d. Date of incurring debt
e. Purpose
f. Monthly or other periodic payment
g. Amount of debt as of date of commencement
h. Amount of current debt
TOTAL: Notes Payable $
F. 6. Brokers Margin Accounts
6.1 a. Name and address of broker
b. Amount of original debt
[UCS Rev. 6/2016 eff. 8/1/16 (8/12/16 version)] Page 20
c. Date of incurring debt
d. Purpose
e. Monthly or other periodic payment
f. Amount of debt as of date of commencement
g. Amount of current debt
TOTAL: Broker’s Margin Accounts
G. 7. Taxes Payable
7.1 a. Description of Tax
b. Amount of Tax
c. Date Due
TOTAL: Taxes Payable $
H. 8. Loans on Life Insurance Policies
8.1 a. 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 debt as of date of commencement
h. Amount of current debt
TOTAL: Loans on Life Insurance
I. 9. Installment accounts payable (security agreements,
chattel mortgages)
9.1 a. Name and address of creditor
b. Debtor
c. Amount of original debt
d. Date of incurring debt
e. Purpose
[UCS Rev. 6/2016 eff. 8/1/16 (8/12/16 version)] Page 21
f. Monthly or other periodic payment
g. Amount of debt as of date of commencement
h. Amount of current debt
TOTAL: Installment Accounts $
J. 10. Other Liabilities
10.1 a. 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 debt as of date of commencement
i. Amount of current debt
10.2 a. 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 debt as of date of commencement
i. Amount of current debt
TOTAL: Other Liabilities $
TOTAL LIABILITIES $
[UCS Rev. 6/2016 eff. 8/1/16 (8/12/16 version)] Page 22
VI. ASSETS TRANSFERRED
List all assets transferred in any manner during the preceding three years, or length of the
marriage, whichever is shorter. Note: 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. LEGAL & EXPERT FEES
Please state the amount you have paid to all lawyers and experts retained in
connection with your marital dissolution, including name of professional, amounts
and dates paid, and source of funds. Attach retainer agreement for your present
attorney.
_____________________________________________________________________
VIII. 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 a part hereof, have been carefully read by the undersigned who states that they are
true and correct and states same, under oath, subject to the penalties of perjury.
_________________________________
Sworn to before me this
day of _____________, 20_ _ This is the _______ Statement of Net Worth
I have filed in this proceeding.
________________________
Notary Public
Attorney Certification:
____________________
REQUIRED ATTACHMENTS:
Retainer Agreement
Most recent W-2, 1099s, K1s and Income Tax Returns
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