Appendix V - Family Part Case Information Statement Form Page 3

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4. Additional Identification:
Confidential Litigant Information Sheet: Filed
Yes
No
5. ATTACH a list of all prior/pending family actions involving support, custody or Domestic Violence, with the Docket Number, County, State
and the disposition reached. Attach copies of all existing Orders in effect.
Complete this section for self and (if known) for other party. If W-2 wage earner,
Part C. - Income Information:
gross earned income refers to Medicare wages.
1. Last Year’s Income
Yours
Joint
Other Party
1. Gross earned income last calendar (year)
$
$
$
2. Unearned income (same year)
$
$
$
3. Total Income Taxes paid on income
Fed., State,
$
$
$
(
F.I.C.A., and S.U.I.). If Joint Return, use middle
column.
4. Net income (1 + 2 - 3)
$
$
$
ATTACH to this form a corporate benefits statement as well as a statement of all fringe benefits of employment. (See Part G)
ATTACH a full and complete copy of last year’s Federal and State Income Tax Returns. ATTACH W-2 statements, 1099’s, Schedule C’s, etc.,
to show total income plus a copy of the most recently filed Tax Returns. (See Part G)
Check if attached:
Federal Tax Return
State Tax Return
W-2
Other
2. Present Earned Income and Expenses
Yours
Other Party
(if known)
1. Average gross weekly income (based on last 3 pay periods –
$
$
ATTACH pay stubs)
Commissions and bonuses, etc., are:
included
not included*
not paid to you.
*ATTACH details of basis thereof, including, but not limited to, percentage overrides, timing of payments, etc.
ATTACH copies of last three statements of such bonuses, commissions, etc.
2. Deductions per week (check all types of withholdings):
$
$
Federal
State
F.I.C.A.
S.U.I.
Other
3. Net average weekly income (1 - 2)
$
$
3. Your Current Year-to-Date Earned Income
Provide Dates: From
To
1. GROSS EARNED INCOME: $
Number of Weeks
2. TAX DEDUCTIONS: (Number of Dependents:
)
a.
Federal Income Taxes
a.
$
b.
N.J. Income Taxes
b.
$
c.
Other State Income Taxes
c.
$
d.
F.I.C.A.
d.
$
e.
Medicare
e.
$
f.
S.U.I. / S.D.I.
f.
$
g.
Estimated tax payments in excess of withholding
g.
$
h.
h.
$
i.
i.
$
TOTAL
$
Revised to be effective September 1, 2017. CN: 10482 (Court Rules Appendix V)
Page 3 of 10

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