Financial Disclosure Affidavit Form (Page 5 of 8) in pdf

Attachment 4

2. What is the name, address, and telephone number of the insurance company paying that settlement to

you?

________________________________________________________________________________________

(Go to 3)

3. What is the name, address, and telephone number of the attorney representing you?

________________________________________________________________________________________

(Go to C)

C. Life Insurance Policy

Do you have a life insurance policy?

Yes. Attach a copy of the declaration page or other documentation from the insurance carrier showing the cash

value of the life insurance policy.

No.

(Go to D)

D. Additional Sources of Income

Do you have other sources of income which have not already been identified in response to the questions

above?

Yes. (Attach documentation showing the source and value of the other sources of income.)

No.

(Go to Step 7)

The Court allows

Step 7: DEDUCTIONS FROM INCOME FOR CHILD SUPPORT STANDARDS ACT:

certain deductions from income prior to applying the child support percentages. List the deductions

on an annual basis:

1. Unreimbursed employee business expenses (except to the extent that those

expenses reduce personal expenses below)

1. $_____________

2. Maintenance actually paid to spouse not a party to this action*

2. $_____________

3. Maintenance actually paid to spouse who is a party to this action

3. $_____________

4. Child support actually paid on behalf of non- subject child(ren)*

4. $_____________

5. Temporary Assistance

5. $_____________

6. Supplemental Security Income

6. $_____________

7. New York City/Yonkers Income Tax

7. $_____________

8. FICA

8. $_____________

Total Deductions from Income for Child Support Standards Act

$ _____________

Attach a copy of the appropriate Court Order.

(Go to Step 8)

Financial Disclosure Affidavit Form Page 5

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