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Affidavit of Facts By Original Creditor

If the affiant has a personal knowledge of the debtor’s debt and the plaintiff’s procedures from business record creation, he/she can execute the following affidavit.

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1 SUPREME COURT OF THE STATE OF NEW YORK	
06/27/05	
COUNTY OF ________________________	
county in  which divorce is pending	
---------------------------------------------------------------x
  Index No. ______________	
           	insert court index no.	
                   Plaintiff,         :  
                                          AFFIDAVIT IN SUPPORT
-against- :OF MOTION FOR      
                TEMPORARY RELIEF
                    Defendant.          :
----------------------------------------------------------------x
STATE OF NEW YORK )
s.s.:
COUNTY OF ________________________)	
            	where this affidavit is signed	
I, ____________________________, being duly sworn, depose and say that:	
             	your name	
1. I am the ______________________ in this action for a divorce.	
             Plaintiff/Defendant	
2. I make this affidavit in support of my Motion for Temporary Relief.  You may
attach copies of any relevant documents in support of your case, please label and refer to them in
your affidavit.
BACKGROUND FACTS
3. We were married on __________________ in ________________________.	
    date of marriage    place of marriage	
4. I am ______ years old and my spouse is ______ years old.	
  	age	              	age	
5. The children of the marriage are:
Name of Person
Child’s Name	
Date of Birth	     Social Security No.	With Whom Child Resides	
______________________________________________________________________________

2 ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
6. I  reside at ________________________________________ and my spouse	
           	your address, or if confidential, state a mailing address   	
resides at ______________________________________.	
                    spouse’s address	
7. This action for a divorce was commenced on _________________________.  A 	
      	date index number was purchased	
copy of the Summons with Notice is attached as Exhibit A./Action is being commenced
simultaneously.
(complete the following sections that apply to your situation)	
‘	 REQUEST FOR A TEMPORARY ORDER OF PROTECTION	
               	
8. Pending the hearing of the instant application and the further Order of
this Court, I request that this Court issue a Temporary Order of Protection which would
order  __________________________ to remain at least 150 feet away from me,  my home
            spouse’s name	
and place of employment, and that  ________________________ refrain from assault, stalking,	
     spouse’s name	
harassment, menacing, reckless endangerment, disorderly conduct, intimidation, threats or any
criminal offense against me and my family by any means, including but not limited to phone
calls and other electronic means such as e-mail.
9. I believe I will be awarded an Order of Protection in this case because: 	
(include
details with names, dates and places of  mental and physical abuse; include the most recent incident, the worst
incident and the first incident)	
______________________________________________________________________________
______________________________________________________________________________

3 ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________	
‘	REQUEST FOR A TEMPORARY ORDER OF PROTECTION FOR THE 
CHILD(REN)
10. Pending the hearing of the instant application and the further Order of
this Court, I also request that this Court issue a Temporary Order of Protection which includes
protection for my child(ren), and which would order________________________to remain
away 	
spouse’s name	
from my child(ren), including my child(ren)’s home, school, babysitter’s home, and child care 
center, and that  ______________________ refrain from assault, stalking, harassment,
menacing,	
spouse’s name	
reckless endangerment, disorderly conduct, intimidation, threats or any criminal offense against
me and my child(ren) by any means, including but not limited to phone calls and other
electronic means such as e-mail.
11. The child(ren) to be covered by the Temporary Order of Protection are:
Child’s Name	
Date of Birth	
____________________________ ______________
____________________________ ______________
____________________________ ______________
____________________________ ______________

4 ____________________________ ______________
12. I believe I will be awarded an Order of Protection that includes protection for
my children in this case because: 	
(include details with names, dates and places of  mental and physical abuse; 
include most recent incident, worst incident and first incident) 	
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________	
‘	REQUEST FOR TEMPORARY CUSTODY
13. I should have custody of the following child(ren) of the marriage, while this
action is pending because:	
(identify the child(ren) you seek custody of and describe in detail your relationship with the children and your
involvement in caring for and raising the children)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

5 ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
14. It is in the child(ren)’s best interests to live with me.	
‘	REQUEST FOR TEMPORARY CHILD SUPPORT
15. A copy of my Statement of Net Worth is attached as Exhibit B.  It details all of
my monthly expenses, income and resources.
16. Upon information and belief, my spouse’s last known income is approximately 
$____________ per year.  My spouse works as a ___________________________________	
         	 amount spouse’s last known occupation	
for _____________________________________ at ________________________________
  	name of spouse’s last known employer     address of spouse’s last employer, if known	
________________________________.
17. Based upon my spouse’s income, I respectfully request an award of temporary 
child support in accordance with the Child Support Standards Act.	
‘	REQUEST FOR VISITATION
18. I should have visitation with the child(ren) of the marriage, while the action is
pending because:	
(identify the child(ren) you seek visitation for and describe in detail your relationship with the children and your
involvement in caring for and raising the children)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

6 ______________________________________________________________________________
_____________________________________________________________________________
______________________________________________________________________________
19. It is in the child(ren)’s best interests that I visit them on a regular basis.	
‘	REQUEST FOR TEMPORARY MAINTENANCE
20. A copy of my Statement of Net Worth is attached as Exhibit B.  It details all of
my monthly expenses, income and resources. 
21. Upon information and belief, my spouse’s last known income is approximately 
$__________ per year.  My spouse works as a ___________________________________	
         amount	                   	spouse’s last known occupation	
for _____________________________________ at ________________________________
     	name of spouse’s last known employer            address of spouse’s last employer, if known	
 ________________________________.
22. As my Statement of Net Worth shows, my income is only $_________________	
       state your income	
from _____________________________________.	
                	state your source of income	
23.  I request an award of  temporary maintenance to help me meet my
monthly expenses in accordance with the standard of living that was established during the
marriage.

7	
‘	REQUEST FOR MEDICAL INSURANCE AND MEDICAL EXPENSES
24. Upon information and belief, my spouse is provided through employment with
medical insurance coverage for the family.
25. I ask this Court to order my spouse to continue to maintain this medical 
insurance coverage for me and my child(ren) during the pendency of this action.  I also 
ask the Court to direct my spouse to provide me with the appropriate insurance identification
cards, claim forms, plan description and information necessary to fully participate in the medical
insurance plan.
26. In addition, I ask that the Court Order my spouse to pay the pro rata share of all
medical, dental and pharmacy expenses that are not covered by insurance.	
‘	REQUEST FOR LIFE INSURANCE
27. I request that the Court Order my spouse to purchase and/or maintain in full force
and effect a life insurance policy on my spouse’s life in an amount sufficient to secure support
obligations and naming me as the irrevocable beneficiary during the pendency of this action.
28. The life insurance policy will provide financial protection for myself and my
child(ren) should my spouse die before support obligations end.	
‘	REQUEST FOR EXCLUSIVE POSSESSION OF THE MARITAL
 RESIDENCE
29. I request exclusive possession of the marital residence  located at:
________________________________________________.	
                                	full address - street, apt. no, city, zip code

8 30. We lived together in the marital residence from ____________ to ____________.	
                   month & year/month & year	
31. The person who currently lives is the marital residence is:___________________.	
           	name	
32. I will suffer the following harm if exclusive possession of the marital residence is 
not awarded to me during the pendency of this action: 
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
‘	REQUEST FOR INJUNCTIVE RELIEF WITH RESPECT TO
PROPERTY OF THE MARRIAGE 	
33. I  request an Order that would prevent my spouse from transferring, hiding
or dissipating the property of the marriage (marital assets) during the pendency of this action.
34. The marital assets include, but are not limited to, the following: 	
(list assets accumulated during the marriage.  Marital assets include, for example, houses, including rental
property, cars, other vehicles, boats, household furnishings, art work, jewelry, interest in a business,  bank accounts,
pensions, retirement funds, tax refunds, etc.)
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

9 35. I believe that an Order that prevents my spouse from transferring, hiding
or dissipating marital assets is necessary because:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
36. The property is marital property because it accumulated during the marriage, and
I believe that I will ultimately be awarded an equitable share of the marital property.
    37. If my spouse disposes of or hides or transfers any of the marital assets, I will be
irreparably harmed because I will never be able to obtain my equitable share of the marital
assets.
38. No prior application has been made for the relief requested herein.
WHEREFORE, I respectfully request that my Motion be fully granted. 
___________________________	
                                                                                                         	sign your name	
Sworn to before me this______day Print name, address and telephone no.
 of _________,200________________________________
(THIS AFFIDAVIT MUST
BE NOTARIZED)	
______________________________
______________________________
Next: Affidavit in Support of Motion for Temporary Relief Previous: Affidavit of Sponsor
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