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.
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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.
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