Download family court of the state of new york, county of st. lawrence sworn

FAMILY COURT OF THE STATE OF NEW YORK, COUNTY OF ST. LAWRENCE
SWORN FINANCIAL STATEMENT
Your Name
Your Address (If P.O. Box or R.D. address, include also the name of the road on which you live)
Your Social Security Number
Your Telephone Number - Home:
Your Employer
Your Date of Birth
Business:
INCOME
EXPENSES
Total
Weekly
* Your weekly wages before deductions
Your weekly wages after Federal, State, and
Social Security (FICA) deductions
(do not include other deductions)
* Other income (specify source: include pensions,
business income, rental income, etc.)
Weekly Amount
Source
Weekly income received by any others in
your household
Name
Source
Amount
Total
A. TOTAL WEEKLY INCOME
$0.00
$0.00
What is the number of dependents you claim for income
tax purposes during the year?
on your income tax return?
What was your total gross income reported on last
year's income tax return?
The prior year's return?
* Rent payment (not mortgage)
(monthly =
Food
* Electricity
(monthly =
Fuel/Cooking
* Fuel/Heating (yearly avg.=
* Telephone
(monthly =
Clothing
Medical
Dental
Drugs
Gas/Transportation
Automobile Repairs
Home maintenance and repairs
Laundry/Drycleaning
Recreation
Babysitter/Day Care
* Cable TV
(monthly =
Taxes
* County/Town (annual =
* School
(annual =
* Village
(annual =
* Sewer and Water
Insurance
* Car
(annual =
* Life
(annual =
* Health
(annual =
Garbage Pickup
Union Dues
School Tuition
School Lunches
School Supplies
Cigarettes
Lottery/OTB
Support/order or alimony
Other (specify)
B. TOTAL WEEKLY LIVING EXPENSES
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$0.00
* Yearly (annual) expenses or income are to be divided by 52 to obtain the weekly expenses or income. Monthly expenses
or income are to be divided by 4.3 to obtain the weekly expenses or income.
NOTICE: You must attach copies of your latest pay stubs and the last two year's income tax returns to this form for
submission to the Court.
MONTHLY PAYMENTS ON LOANS AND DEBTS
(include credit union payments, garnishments and mortgage payments)
Date of Original
Loan or Debt
To Whom Paid
For What
Monthly Payment (if
you are making one)
Balance Due
TOTAL MONTHLY PAYMENTS ON LOANS OR DEBTS $0.00
Divide by 4.3
C. TOTAL WEEKLY PAYMENTS ON LOANS OR DEBTS =
A. TOTAL WEEKLY INCOME
B. TOTAL WEEKLY EXPENSES
C. TOTAL WEEKLY DEBTS
$0.00
$0.00
$0.00
ASSETS
LOCATION
MARKET VALUE
Real Property
NAME & YEAR
VALUE
BANK NAME
AMOUNT
WHAT & WHERE
VALUE
Motor Vehicles and Boats/Trailers/Etc.
Checking and Savings accounts
Other assets including
Stocks and Bonds
If you have transferred any asset in the last three years, complete the following for each asset transferred:
1. Asset transferred
Date of transfer
Value received
To whom transferred
2. Asset transferred
Date of transfer
Value received
To whom transferred
VERIFICATION
STATE OF NEW YORK
)
COUNTY OF ST. LAWRENCE )
, being duly sworn, depose and say that I have read the
I,
contents of the foregoing financial statement and that the same is true to my own knowledge.
Your signature
Sworn to me this
day of
_____________________________________
Notary Public
,
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