Financial Disclosure Affidavit - Nyc Page 2
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2OCSE-388 (E) 11/2008
Rev. 05/2016
Assets
Savings Account:
Bank name: ___________________
Balance: $ _____________
Checking Account:
Bank name: ___________________
Balance: $ _____________
Automobile:
Year: __________ Make: ________
Value: $ _______________
Model: _______________________
House/Apt Owned:
Address: _______________________________________________
Market value: $__________________ Mortgage: $________________
Other assets:
Details: _____________________
Value: $ _______________
(other real estate, car,
boat, snowmobile, stocks,
Details: _____________________
Value: $ _______________
bonds, trailer, etc.)
(Include additional page of other assets, if needed.)
Expenses: The following expenses are ☐ monthly ☐ weekly.
Rent or mortgage:
$ _________
Health insurance:
$ _________
Utilities
Other insurance
Gas:
$ _________
Life:
$ _________
Phone/TV/internet:
$ _________
Auto:
$ _________
Electric:
$ _________
Home/Fire:
$ _________
Other: ______________
$ _________
Other: ______________
$ _________
Child care:
$ _________
Transportation
Auto payment:
$ _________
School tuition and expenses:
$ _________
Gasoline:
$ _________
Food:
$ _________
Public transportation:
$ _________
Clothing:
$ _________
Medical/Dental/Prescription:
$ _________
Other: ________________ $ _________
How many people are in your household?
Me + ________ others
Loans and Debt: Only list the loans and debts you are actually paying.
Owed to: ____________________________________ For: __________________________
Payment: $_____________ ☐ monthly ☐ weekly
Balance: $_________________
Owed to: ____________________________________ For: __________________________
Payment: $_____________ ☐ monthly ☐ weekly
Balance: $_________________
(Include additional page of other loans and debt, if needed.)
STOP! Take this document to a Notary Public BEFORE signing it.
I swear that the above information is true and correct as of
__________________.
(date)
______________________________________
Signature
Sworn to before me
on ________________________________
___________________________________
Notary Public / (Deputy) Clerk of the Court
Financial Disclosure Affidavit – Short version
Page 2 of 2
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