Financial Disclosure Affidavit - Nyc

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OCSE-388 (E) 11/2008
Rev. 05/2016
F.C.A. §§ 413-1, 424-a; Art. 5-B
D.R.L. §§ 236-B, 240
Docket #:
File #:
Income and Expenses Statement
This form is used to give the court information about your financial situation.
 Complete both pages of this form. Sign it only if you’re in front of a notary.
 Bring the following to your next court date:
This form
Copy of your W-2s and/or 1099 statements
Copy of your two (2) most recent pay stubs
Bring all documents to prove the amount of other
Copy of your most recent tax returns, federal
income and/or debt and loans
and state or IRS letter that shows that you do
Proof of health insurance coverage (insurance card)
not have to file taxes
Proof of public assistance
Name: _____________________________________
Date of Birth: _____________
Child’s Name
Child’s Date of Birth
Child Lives With
Are you paying additional child support orders?
Yes
No
How much? $ ___________ To whom? _____________________________
Income: Are you self-employed?
Yes
No
Employer: __________________________________ Hours worked per week: _______
Address: ______________________________________________________________
Gross weekly salary or wage: $___________________
Income from other sources:
$___________________
(public assistance, rent, part-time job, tips, dividends, etc.)
Income from other household members: $___________________
Health Insurance Coverage
My insurance coverage is ☐ through my job ☐ privately purchased ☐ Medicaid
☐ I don’t have health insurance coverage.
My coverage includes ☐ Medical ☐ Dental ☐ Vision ☐ Prescription ☐ All
Insurance Plan Name: ____________________________ Policy #: ________________
I pay/contribute $___________ ☐ weekly ☐ every two weeks ☐ monthly
☐ for a Family Plan.
☐ for an Individual Plan. A Family Plan would cost $_________ ☐ weekly ☐ every
two weeks ☐ monthly
The child(ren)’s health insurance is covered by ☐ my plan ☐ the other parent’s plan
☐ Child Health Plus ☐ Medicaid ☐ Private Insurance: _____________________
Financial Disclosure Affidavit – Short version
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