Affidavit of Net Worth (Child Support)
Providing a sworn statement related to a child support case requires the execution of this affidavit by the parent who is making that statement.
DownloadExtracted Text for Proper Search
1 NONCUSTODIAL PARENT: DATE: CUSTODIAL PARTY: NEW YORK CASE IDENTIFIER: AFFIDAVIT OF NET WORTH I, ______________________________________, being duly sworn, swear that the following is an accurate statement of my income, deductions, expenses, health insurance information, employer information, and home address information: 1. Did you file a Federal Income Tax Return for tax year 2016 ? YES NO If "YES", indicate your total income as reported on your 2016 Federal Income Tax Return: Copy from: 2016 IRS Form 1040, Line 22; or 2016 IRS Form 1040-A, Line 15; or 2016 IRS Form 1040EZ, Line 4. 1.__________ a. If "NO", calculate your total income for 2016 as it should be reported on your Federal Income Tax Return by completing the following. (If none, write "0"): 1. Wages, salaries, tips, etc. __________ 2. Taxable interest income __________ 3. Dividend income __________ 4. Ta xable refunds, credits, or offsets of state and local taxes __________ 5. Alim ony received __________ 6. B usiness income or (loss) __________ 7. Capit al gain or (loss) __________ 8. Other gains or (losses) __________ 9. Taxable amount IRA distributions __________ 10. Ta xable amount of pensions and annuities __________ 11. R ental real estate, royalties, partnerships, S corp. , trust, etc. __________ 12. Farm income or (loss) __________ 13. Unemployment compensation __________ 14. Taxable amount of social security benefits __________ 15. Other income [identify] _______________ __________ Total (add lines 1 - 15) 1 a.__________ 2 2. For your 2016 income, provide the dollar amount for each of the following types of income, if any, which are not included in 1 or 1a above. (If all such income was included, or if you had no income of that type, make a checkmark in the box that applies): Amount Not All None Type of Income Included Above In cluded Above Received a. Investment Income (Less amount expended) __________ b . Deferred Income/Compensation __________ c. Worker’s Compensation __________ d . Disability Benefits __________ e. Unemployment Insurance Benefits __ ________ f. Social Security Benefits __________ g. Veteran’s Benefits __________ h . Pensions and Retirement Benefits __________ i. Fellowships and Stipends __________ j. Annuity Payments __________ Total (add lines a – j ) 2.__________ 3. Were you self-employed at any time during 2016? YES NO (skip to question 4) If "YES", indicate the dollar amount of self-employment deductions you had in 2016 for the following: a. Depreciation deduction greater than depreciation calculated on a straight-line basis for purposes of determining business income or investment credits (if none, write "0") 3a.__________ b. Entertainment and travel allowances deducted from business income to the extent those allowances reduced personal expenditures (if none, write "0") 3b.__________ 3 4. Were you employed by or did you receive compensation from a corporation, S corporation, limited liability corporation, partnership, limited liability partnership, sole proprietorship other bu siness entity at any time during 2016 ? YES NO (skip to question 5) If "YES", indicate the dollar amount of perquisites and fringe benefits received as part of compensation for employment: a. Meals, lodging, memberships, automobiles or other perquisites to the extent they constitute expenditures for personal use, or which directly or indirectly confer personal economic benefits (if none, write "0") 4a.__________ b. Fringe Benefits (if none, write "0") 4b.__________ 5. Indicate the dollar amount of money, goods, or services provided by relatives and friends during 2016 (if none, write "0"): a. Money _______________ b. Goods _______________ c. Services _______________ Total (add lines a – c) 5.__________ 6. Indicate the current dollar value of non-income producing assets (if none, write "0"): a. Houses/Buildings _______________ b. Land _______________ c. Automobiles _______________ d. Boats _______________ e. Motor Homes _______________ f. Campers/Trailers _______________ g. Motorcycles _______________ h. Snowmobiles _______________ i. Coin, Stamp, Art collection _______________ j. Jewelry _______________ k. Other Assets _______________ Total (add lines a – k) 6.___________ 4 7. List below the type of, and dollar value of, any assets you transferred within the past three (3) y ears (PLEASE PRINT - attach additional pages if needed): 8 . Indicate the amount, if any, of the following expenses, payments, or income which you have incurred, paid, or received during 2016 (if none, write "0"): a. Unreimbursed employee business expenses except to the __________ e xtent said expenses reduce personal expenditures b. Alimony or maintenance actually paid to a spouse who is not __________ a party to this action (provide copy of court order or validly executed written agreement) c. Alimony or maintenance actually paid to a spouse who is a __________ party to this action (provide copy of court order or validly executed written agreement) d. Child Support actually paid on behalf of any child who is __________ not subject to this action (provide copy of court order or validly executed written agreement, and proof of payment) e. New York City or Yonkers income taxes or earnings taxes __________ actually paid f. Federal Insurance Contributions Act (FICA) taxes actually __________ paid Total (add lines a – f) 8.__________ 9 . List your current sources of income. (PLEASE PRINT - attach additional pages if needed): a. Employment (name, address, and telephone number of each current employer): Gross Salary (before deductions) $ __________per ( hour day w eek bi - weekly sem i- monthly monthly year ) b. Other current sources of income: Type ____________ Amount of Income $__________ per ( hour day w eek bi-weekly semi-monthly monthly year) 5 10. Are your children who are the subject of the court order covered by health insurance provided by your employer or any organization such as a labor union? Yes , my children are currently enrolled in a health insurance plan provided by my employer or organization: Insurance carrier (PLEASE PRINT)_______________________________________________________ Address of carrier (PLEASE PRINT)______________________________________________________ Plan Number _______________ Policy Number _______________ T ype of coverage _______________________________________ No . Although health insurance for my children is offered by my employer or organization, they are not currently enrolled. No . Health insurance for my children is not offered by my employer or organization. No . I am not currently employed. 1 1. If you changed employers or sources of income during the past year, list prior employers and income sources (PLEASE PRINT - attach additional pages if needed): a. Prior employment (Name, Address and Telephone number of each prior employer): Gross Salary (before deductions) __________per ( h our day w eek bi- weekly semi-monthly monthly year) b. Other prior sources of income: Type ____________ Amount of Income $__________ per ( h ou r day w eek bi-weekly semi-monthly monthly year) 1 2. Indicate your child care expenses and child educational expenses, if any (PLEASE PRINT) and attach supporting documentation, i.e., copies of bills or a letter from the child care provider: 6 a. Child care for children while custodial parent is employed or receiving elementary, secondary or higher education or vocational training: $_____________per ( hour day w eek bi-weekly semi-monthly monthly year) Name of child(ren) in child care: b. Ch ild care for children while custodial parent is seeking employment: $_____________per ( hour day week bi-weekly semi-monthly monthly year) Name of child(ren) in child care: c . Education expenses for children: $_____________per ( hour day week bi-weekly semi-monthly monthly year) Name of child(ren) with education expenses: Please print the following information: ________________________________________________ Name ________________________________________________ Address ________________________________ _____ _________ City State Zip Code (_____)______________ (______)______________ xxx_-xx-____ _____ Daytime Ph one Number Evening Phone Number Social Security Number 7 AFFIRMATION: "All of the information I have provided on this affidavit, and the supporting d ocumentation consisting of ____ pages which I have attached to this affidavit, is true and correct to the best of my knowledge." _______________________________________________________ ______________\ ______ Your Signature Date S worn to me this _____ day of ____________. _______________________________________________ Notary Signature RETURN THIS COMPLETED AFFIDAVIT TO THE CSEU AT THE FOLLOWING ADDRESS: IMPORTANT: PLEASE BE SURE TO INCLUDE ALL OF YOUR SUPPORTING DOCUMENTATION FOR THIS AFFIDAVIT AS WELL AS ALL OTHER DOCUMENTS YOU ARE REQUIRED TO SUBMIT.
If you want to remove Affidavit of Net Worth (Child Support) from this website please contact us providing the reasons together with this url: https://formsarchive.com/affidavit-of-net-worth-child-support/