ࡱ>  ]bjbj:0:0 8XZgXZgUF ,,,8dH,]4!"6!6!6!#L%']!]!]!]!]!]!]$E]'##"''E]6!6!JZ]$`,`,`,'F6!6!]`,']`,`,_QKT6!o$'Z{R" ]~]<]R0e.)0eDKT0eKT''`,'''''E]E]+d''']''''0e''''''''' X : FINANCIAL DISCLOSURE AFFIDAVIT CSMS Case ID No: ______________________ Local District Name: ________________________ Complete all items in blue or black ink. Include copies of your 2007 Federal and State income tax returns, your W-2s, current paycheck stubs and other proof of income, benefits, assets, allowable deductions, expenses, and liabilities. Label each document according to the question to which it is responsive (e.g. your 2007 Federal tax return would be 1A; your current paycheck stub would be 2B, etc.). I ________________________________________, _______________________, and _________________ Name Social Security Number Date of Birth residing at ______________________________________________, being duly sworn, depose, and say that Address the following is an accurate statement as of ________________, of my gross income, benefits, and financial Date assets, wherever situated. Complete Steps 1 8 by checking all that apply, and then sign the affidavit in Step 9 in the presence of a notary public. Step 1: INCOME FROM ALL SOURCES: The correct amount of the child support obligation is presumed to be a percentage of income as defined by law. The percentages are set forth in Addendum A. Other important information is set forth in Addenda B, C, and D. List your income from all sources as follows: A. I am providing the following documentary proof:  FORMCHECKBOX  A copy of my 2007 federal tax return  FORMCHECKBOX  A copy of my 2007 state tax return  FORMCHECKBOX  A copy of my W2 statement(s) OR B. I affirm one of the following:  FORMCHECKBOX  I did not earn any income in 2007 and no federal or state filing was required for that tax year.  FORMCHECKBOX  The amount of income that I earned in 2007 was not enough to meet the filing requirements for a federal or state tax return so no tax returns are included.  FORMCHECKBOX  If a W-2 was received, I have attached a copy.  FORMCHECKBOX  I do not have access to my income records, including my 2007 federal or state income tax return(s) and W-2 information, so no information is included.  FORMCHECKBOX  Attached is a letter or other documentation from an institution (Correctional Facility, Shelter, Hospital, other) attesting to why my income records are unavailable. List Documentation: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ (Go to Step 2) Step 2: CURRENT EMPLOYMENT INFORMATION A. Are you currently employed?  FORMCHECKBOX  Yes (Go to B)  FORMCHECKBOX  No (Go to Step 3) B. I have attached one of the following:  FORMCHECKBOX  A copy of my current paycheck stub(s)  FORMCHECKBOX  A signed letter from my employer(s) stating the amount of income I am/will be earning. (Go to Step 3) Step 3: BENEFIT INFORMATION A. Are you currently receiving benefits?  FORMCHECKBOX  Yes (Go to B)  FORMCHECKBOX  No (Go to Step 4). B. What benefits are you receiving?  FORMCHECKBOX  Unemployment Insurance Benefits  FORMCHECKBOX  Supplemental Security Income  FORMCHECKBOX  Social Security Disability  FORMCHECKBOX  Workers Compensation  FORMCHECKBOX  Temporary Assistance or Care or Safety Net Assistance  FORMCHECKBOX  Veterans Benefits  FORMCHECKBOX  in lieu of retired military pay  FORMCHECKBOX  not in lieu of military pay  FORMCHECKBOX  Retirement / Pension benefits  FORMCHECKBOX  Other (identify): ________________________________________________________________________________________________________________________________________________________________________________________ (Go to C) C.  FORMCHECKBOX  Attached is documentation from each benefit payer above, with the amount and frequency of each benefit. (Go to Step 5). Step 4: NON-EMPLOYMENT INFORMATION A. If you are not working or collecting benefits, please explain why in the space provided: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ (Go to B) B. If you are not working or collecting benefits, explain how you are paying your bills in the space provided: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ (Go to C) C. Do you claim an inability to earn income or receive benefits?  FORMCHECKBOX  Yes (Go to D)  FORMCHECKBOX  No (Go to Step 5) D. If you claim an inability to earn income or receive benefits, you must provide documentary proof of this inability.  FORMCHECKBOX  I am attaching the following letter or other documentation from an institution (for example, a Correctional Facility, Shelter, Hospital, other) to support my claim that I am unable to earn income or receive benefits. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ (Go to Step 5) Step 5: CASH AND ASSET INFORMATION A. Cash Do you currently have access to cash?  FORMCHECKBOX Yes. I have access to approximately $_________________ in cash.  FORMCHECKBOX No. (Go to B) B. Bank and Financial Accounts 1. Do you have banking and/or financial accounts?  FORMCHECKBOX  Yes. (Go to 2)  FORMCHECKBOX No. (Go to C) 2. Do you have a checking account?  FORMCHECKBOX  Yes. Attach a copy of the most recent statement for this account.  FORMCHECKBOX  No. (Go to 3) 3. Do you have a savings account, CD, or Money Market Account?  FORMCHECKBOX  Yes. Attach a copy of the most recent statement for each account.  FORMCHECKBOX  No. (Go to C) C. Inmate Commissary Account Do you have an inmate commissary account?  FORMCHECKBOX  Yes. I have attached a copy of the most recent statement for my commissary account.  FORMCHECKBOX  No. (Go to D) D. Stocks, Bonds, and Investments Do you have any of the following? (Check all that apply)  FORMCHECKBOX  stock in a corporation or other entity  FORMCHECKBOX  bonds  FORMCHECKBOX  mutual funds  FORMCHECKBOX  a retirement account  FORMCHECKBOX  Yes. Attach documentation showing the value of each.  FORMCHECKBOX  No. (Go to E) E. Real Property Do you own any of the following? (Check all that apply)  FORMCHECKBOX  home  FORMCHECKBOX  land  FORMCHECKBOX  rental property  FORMCHECKBOX  Yes. Attach a copy of the latest appraisal or other documentation attesting to the value of your real property.  FORMCHECKBOX  No. (Go to F) F. Personal Property Do you own a motor vehicle, motorcycle, or other recreational vehicle?  FORMCHECKBOX Yes. Attach a copy of the title(s) or registration document(s).  FORMCHECKBOX No (Go to Step 6) Step 6: OTHER SOURCES OF INCOME A. Lawsuits 1. Are you a party to a lawsuit which may result in the transfer of income or assets to you, or to another party?  FORMCHECKBOX Yes. (Go to 2)  FORMCHECKBOX No. (Go to B) 2. Has the lawsuit settled?  FORMCHECKBOX Yes. Attach documentation showing the settlement date and terms of the settlement which transfer income or assets to you or from you to another party.  FORMCHECKBOX No. (Go to 3) 3. What is the name, address, and telephone number of the attorney representing you? _____________________________________________________________________________________ (Go to B) B. Insurance Settlements 1. Are you currently receiving, or will you be receiving, proceeds from an insurance settlement?  FORMCHECKBOX Yes. Attach documentation showing the settlement date, claim number, and amount. (Go to 2)  FORMCHECKBOX No. (Go to C) 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?  FORMCHECKBOX Yes. Attach a copy of the declaration page or other documentation from the insurance carrier showing the cash value of the life insurance policy.  FORMCHECKBOX 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?  FORMCHECKBOX Yes. (Attach documentation showing the source and value of the other sources of income.)  FORMCHECKBOX No. (Go to Step 7) Step 7: DEDUCTIONS FROM INCOME FOR CHILD SUPPORT STANDARDS ACT: The Court allows 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) Step 8: ANNUAL EXPENSE AND LIABILITY INFORMATION A. Expenses: In ordering support by the percentages the Court is not obligated to consider expenses. However, if the Court varies from the percentages, expenses may be considered. List all expenses on an annual basis: 1. Rent or mortgage payment 1. $_____________ 2. Mortgage interest and amortization 2. $_____________ 3. Realty taxes (if not included in mortgage payment) 3. $ _____________ 4. Insurance on realty 4. $ _____________ 5. Utilities: gas electric/ water telephone cable _ 5. $ _____________ 6. Garbage collection 6. $_____________ 7. Household repairs (specify: 7. $ _____________ 8. Food 8. $ _____________ 9. Auto expenses: gas maintenance insurance & fees loan 9. $ _____________ 10. Public transportation 10. $ _____________ 11. Life insurance 11. $ _____________ 12.Health insurance 12. $ _____________ 13. Clothing: self $ others $ (explain: ) 13. $ _____________ 14. Laundry and dry cleaning 14. $ _____________ 15. Education and tuition (explain: ) 15. $ _____________ 16. Child care 16. $ _____________ 17. Contributions 17. $ _____________ 18. Union dues (mandatory: yes no ) 18. $ _____________ 19. Entertainment 19. $ _____________ 20. Miscellaneous personal expenses (specify: ) 20. $ _____________ 21. Other (specify: ) 21. $ _____________ Total Expenses $ _____________ (Go to B) B. Liabilities, loans and debts: In ordering support by the percentages the Court is not obligated to consider liabilities, loans, and debts. However, if the Court varies from the percentages, they may be considered. List your liabilities, loans and debts as follows: 1. Creditor 2. Creditor 3. Creditor Purpose Purpose Purpose Date incurred Date incurred Date incurred Total balance due $ __ Total balance due $ Total balance due $ ________ Total Liabilities, loans and debts = (1+2+3) $_______________ (Go to Step 9) Step 9: AFFIRMATION The foregoing statements and a rider consisting of ____ page(s) annexed hereto and made a part thereof, have been carefully read by the undersigned. I affirm that the foregoing is true and correct and represents all income, benefits, and assets held by me or due and owing to me, as well as all expenses, liabilities, loans and debts incurred by me. At the time of signing this Affidavit I have no knowledge of any additional source(s) of income, benefits, and assets to which I am entitled. I understand that the Support Collection Unit (SCU) is relying upon the information that I am providing herein in its determination as to whether I am eligible for an agreement for a modification of my support order and/or a compromise of support arrears pursuant to this pilot program. I understand that failure to disclose, in full, information that is pertinent to the questions above could result in denial of my request for modification of my support order and/or arrears compromise. I further understand that if I present the SCU with false or misleading information, or a misrepresented claim, which is used as the basis for an Agreement to Modify Order of Support and/or Compromise Arrears (Agreement), and the Agreement is then accepted by the court and a modified order of support is issued based on such information, the SCU may bring a motion to vacate and nullify such order. In such instance, the SCU has the right to request permission from the court to re-apply all amounts affected by the compromise to my account, reinstate previously existing judgments of arrears, disregard the modified order, and enforce the prior order. I understand that if the modified order is vacated by the court, the SCU will take any action or institute any and all proceedings which might have been taken if the Agreement had not been entered into. I solemnly affirm under the penalty of perjury that the above information is true to the best of my knowledge, information and belief. _________________________________ ____________________ Signature of Noncustodial Parent Date Sworn to before me this __________ Day of_________________ , 20___ _____________________________ Notary Public ADDENDUM A CHILD SUPPORT PERCENTAGES The child support percentages that shall be applied by the Court unless the Court makes a finding that the non-custodial parents share is unjust or inappropriate are as follows: 17% for one child; 25% for two children; 29% for three children; 31% for four children; and no less than 35% for five or more children. ADDENDUM B COMBINED PARENTAL INCOME OVER $80,000.00 Where combined parental income exceeds $80,000.00, the Court shall determine the amount of child support for the amount of the combined parental income in excess of such dollar amount through consideration of the factors set forth in Addendum D and or the support percentage set forth in Addendum A. ADDENDUM C SELF-SUPPORT RESERVE Where the annual amount of the basic child support obligation would reduce the non-custodial parents income below the poverty income guidelines amount for a single person as reported by the federal Department of Health and Human Services, the basic child support obligation shall be twenty-five dollars per month unless the interests of justice dictate otherwise. Where the annual amount of the basic child support obligation would reduce the non-custodial parent's income below the self-support reserve but not below, the poverty income guidelines amount of a single person as reported by the federal Department of Health and Human Services, the basic child support obligation shall be fifty dollars per month or the difference between the non-custodial parent's income and the self-support reserve, whichever is greater. ADDENDUM D VARIANCE FROM THE PERCENTAGES The Court has the discretion to vary from the percentages if it finds that the non-custodial parent's pro-rata share of the basic child support obligation is unjust or inappropriate. This finding shall be based upon consideration of the following factors: I. The financial resources of the custodial and non-custodial parent, and those of the child. 2. The physical and emotional health of the child and his/her special needs and aptitudes. 3. The standard of living the child would have enjoyed had the marriage or household not been dissolved. 4. The tax consequences to the parties. 5. The non-monetary contributions that the parents will make toward the care and well-being of the child. 6. The educational needs of either parent. 7. A determination that the gross income of one parent is substantially less than the other parent's gross income. 8. The needs of the children of the non-custodial parent for whom the non-custodial parent is providing support who are not subject to the instant action and whose support has not been deducted from income, and the financial resources of any person obligated to support such children, provided, however, that this factor may apply only if the resources available to support such children are less than the resources available to support the children who are subject to the instant action. 9. Provided that the child is not on public assistance (I) extraordinary expenses incurred by the non-custodial parent in exercising visitation, or (ii) expenses incurred by the non-custodial parent in extended visitation provided that the custodial parent's expenses are substantially reduced as a result thereof. 10. Any other factors the Court determines are relevant in each case. NOTE: The language in the above Addenda is paraphrased from that in the statute for the purposes of simplification. For statutory language, see Family Court Act Sections 413(1), 416 and 424-a and Domestic Relations Law Sections 236-B and 240.      Attachment 4 PAGE  PAGE 1 Attachment 4 FGovw     ǾپxlcccZNhh[45^JaJhF5^JaJhL15^JaJhh 5^JaJhm5^JaJhh 5^JaJhha5^JaJhh5CJ^JaJhha5CJ^JaJhehaCJheh8oCJheh3CJhehE[CJheh&CJhehqCJh ha5 h ha h`+E5G> @ eRI %gd$ hhd^ha$gd+_ hH0 %d^gd hH0 %d@&^gd $ hH0 %da$gdah^hgdq /0  ` 0p@ "%gda#$ 20  ` 0p@ "%@&a$gd   ! 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