Financial Disclosure Affidavit Page 3
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8Form 4-17
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9.
Public Assistance
9. $________ per __________
10. Food Stamps
10. $________ per __________
e. Income from other sources: (List here and explain any other income including but not limited to: non-
income producing assets; employment “perks” and reimbursed expenses to the extent that they reduce
personal expenses; fringe benefits as a result of employment; periodic income, personal injury settlements;
non-reported income; and money, goods and services provided by relatives and friends):
____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
II. ASSETS: The Court can consider the assets of the custodial parent and/or the non-custodial parent in its
award of child support. List your assets as follows:
a. Savings account balance (Name of bank: _________________________ )
a. $_______________
b. Checking account balance (Name of bank: ________________________)
b. $_______________
c. Automobile(s) (Year and make: ________________________________ )
c. $_______________
Loan information ____________________________________________
d. Residence owned (Address: ____________________________________)
d. $_______________
e. Other real estate owned _______________________________________
e. $_______________
f.
Other assets (For example: stocks, bonds, trailers, boat, etc.) __________
f. $_______________
___________________________________________________________
g. Driver's, professional, recreational, sporting and other licenses and permits held (provide name of issuing
agency, license number and attach a copy if possible) __________________________________________
_____________________________________________________________________________________
NOTE: ATTACH TO THIS FORM ANY INFORMATION AS TO ANY ADDITIONAL ASSETS.
III. DEDUCTIONS FROM INCOME: The Court allows certain deductions from income prior to applying
the child support percentages. List the deductions that apply to you as follows:
a. Unreimbursed employee business expenses
a. $_______________
b. Maintenance actually paid to spouse not a party to this action*
b. $_______________
c. Maintenance actually paid to spouse who is a party to this action
c. $_______________
d. Child support actually paid on behalf of non- subject child(ren)*
d. $_______________
e. Public Assistance and Food Stamps
e. $_______________
f.
Supplemental Security Income
f. $_______________
g. NYC/Yonkers Income Tax
g. $_______________
h. Social Security/Medicare Taxes
h. $_______________
*Attach to this form a copy of the appropriate Court Order
IV. HEALTH INSURANCE, UNREIMBURSED HEALTH-RELATED EXPENSES, CHILD CARE
EXPENSES, EDUCATIONAL EXPENSES AND LIFE AND ACCIDENT INSURANCE POLICIES:
As part of the child support obligation, parents must be directed to provide health insurance coverage, pay a
pro-rated share of the cost or premiums to obtain or maintain the health insurance coverage, a pro-rated share
of unreimbursed health-related expenses, pro-rated share of child care expenses and, in the Court's discretion,
educational expenses. The Court may direct you to purchase and maintain life and/or accident insurance
benefits or assign benefits on existing policies for the benefit of your children. List your information as follows
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