Financial Disclosure Affidavit printable pdf download

Financial Disclosure Affidavit

F.C.A. §§413-1, 424-a; Art. 5-B

Form 4-17

D.R.L. §§236-B, 240

(Financial Disclosure Affidavit)

10/2012

FAMILY COURT OF THE STATE OF NEW YORK

COUNTY OF

.............................................................................................

In the Matter of a Proceeding for Support

Docket No.

(Commissioner of Social Services, Assignor,

on behalf of

, Assignee)

FINANCIAL

Petitioner

DISCLOSURE

AFFIDAVIT

-against-

Respondent.

.............................................................................................

Notice: Your signature on this form must be notarized. You are required to

attach to this form the following documents:

• Current and representative paycheck stub(s);

• Copies of your most recently filed state and federal income tax returns,

including all forms;

• A copy of the W-2 wage and tax statement(s) submitted with the returns

OR, if you did not file tax returns, a copy of your W-2 form for the most

recent year for which you filed tax returns;

• Information relating to health insurance plans available to you for the

provision of insurance, health care, dental care, optical care, prescription

drug and other pharmaceutical and health-related benefits for the

child(ren) for whom support is sought, including the costs for adding the

child(ren) to such plans; and

• Information relating to accident and life insurance plans.

STATE OF NEW YORK )

):ss.:

COUNTY OF

)

I, _________________________________, the (Petitioner) (Respondent) herein, residing at ______________

__________________________________,

being duly sworn, depose and say that the following is an accurate

Unless ordered confidential, pursuant to Family Court Act §154-b, because of a risk that disclosure would

place the health, safety or liberty of the party at risk. See Form GF-21 and GF-21a, available at

Financial Disclosure Affidavit