WPC i8jQ/(2Z1֫1(Z"LkGy)ϖL74\QyӧP;Fv]fa1 —`%+OΝoњjlN*N$[j`'A<Aƅ떭h?l _6ւR۪LDJ0-BĖ6 9'I`Q;(nINXgc:q<ݾ^\tj Ѓxj-t dG.qdjQ7$@bt}Lo,TMgUasaz,ZسqC NpsD/gˑ\S}-6*XO)5ЮvI͵cÆ:om`753{w1D+eF?dp\u?,c}hCuV'MzwXuq>Mg_ϦaztO-Hb m|aԅ$RԞrx2Uu"L^  %NU@w402 0(A 0Di m 0D"Terri Porter $SUPREME COURT l,Converted by WordPort from source file mat003.doc ."0Kathy Hughes21 X(9 Z(Times New Roman O23|x($(2#$  !  U(2#$  !   !  _  XXXXXSUPREMECOURT  COUNTYOF___________________     p      x IndexNo.  ________  ! X!----------------------------------------------------------- L  $ p$  Plaintiff, p STATEMENTOF  `    p NETWORTH  L  'm ph'   m -against- p (_DRL_Ԁ236)  8    Defendant. m  p Dateofcommencementofaction:   d8    m  p ____________ 8 ' m  '----------------------------------------------------------- $ $ h$STATEOFNEWYORK h )   h )ss.:  COUNTYOF______________ h ) p Completeallitems,marking NONE, INAPPLICABLEAND UNKNOWN(ifappropriate) 4 ! h4!  ________________,the[Petitioner/Respondent/Plaintiff/Defendant]herein,beingduly H sworn,deposesandsaysthatthefollowingisanaccuratestatementasof[date],ofmynetworth 4 (assetsofwhatsoeverkindandnatureandwhereversituatedminusliabilities),statementof   incomefromallsourcesandstatementofassetstransferredofwhatsoeverkindandnatureand   whereversituated: !  h0   I.  FAMILYDATAl$"(#(# 0   (a)  Husbandsage______________________X% #(#(# 0   (b)  Wifesage______________________D&!$(#(# _0   (c)  Datemarried______________________0'"%(#(# 0   (d)  Date(separated)(divorced)______________________(l#&(#(# 0   (e)  Numberofdependentchildrenunder21years_____________)X$'(#(# 0   (f)  Namesandagesofchildren)D%((#(# 0  ______________________*0&)(#(# 0  ______________________+'*(#(# 0  ______________________,(+(#(# $X$0   (g)  CustodyofChildren  []Husband  []Wife-(,(#(# *p*0   (h)  Minorchildrenofpriormarriage  []Husband p []Wife(#(# 0   (i)  [Husband/Wife][paying/receiving]$________asalimony(maintenance)and/or  $________childsupportinconnectionwithpriormarriage(#(# 0   (j)  Custodyofchildrenofpriormarriaget(#(# 0  Name____________________________________________`(#(# 0  Address__________________________________________L (#(# -Q-0   (k)  Ismaritalresidenceoccupiedby  []Husband Q []Wife  []Both8 (#(# 0   (l)  Husbandspresentaddress______________________________________________$ t(#(# 0  Wifespresentaddress_________________________________________________ `(#(# 0   (m)  OccupationofHusband_________________OccupationofWife_________________ L (#(# 0   (n)  Husbandsemployer_________________________________ 8 (#(# 0   (o)  Wifesemployer____________________________________$ (#(# 0   (p)  Education,trainingandskills(includedatesofattainmentofdegrees,etc.) (#(# 0  Husband Tj XXԀ________________________________________________________________________ (#(# XX  Tj0  Wife Tj XXԀ____________________________________________________________________________ (#(# XX  Tj0   (q)  Husbandshealth__________________ (#(# 0   (r)  Wifeshealth_____________________p(#(# 0   (s)  Childrenshealth__________________\(#(# 0   Ia.  HEALTHCOVERAGEINFORMATION p(#(# 0? (#Qe00    HUSBAND'SPLAN ?   WIFE'SPLAN4(#(# GroupHealthPlan#1Name:  _________________ ? _________________   AddressforPlan#1:  _________________ ? _________________   Identificationnumber-Plan#1  _________________ ? _________________  Planadministrator-Plan#1  _________________ ? _________________  Typeofcoverage-Plan#1  _________________ ? _________________  0    HUSBAND'SPLAN ?   WIFE'SPLAND!(#(# GroupHealthPlan#2Name:  _________________ ? _________________ 0"  AddressforPlan#2:  _________________ ? _________________ #l! Identificationnumber-Plan#2  _________________ ? _________________ $X" Planadministrator-Plan#2  _________________ ? _________________ $D # Typeofcoverage-Plan#2  _________________ ? _________________ %0!$ -?? -0   Ib.  ALTERNATERECIPIENTSOFHEALTHCOVERAGE(#'(#(# * ddd Xdd Xdd X(#(#,;ZZ,ZZ,ZZ,-ZZ,<ZZ+  ()$()$ 2($ ?$  ')%)  '! E? !  0 @ NAMESOFCHILDREN ')%*  '$ g?E$  0 @ DATEOFBIRTH ')%+  '$ $?g$  0 @ SOCIALSECURITY# ')%,  '  0 @ ADDRESS 1')%-  2 21' b?$'  0 @ 1 '*I&.  '' E? b'  '*I&/  '$ ?E$  '*I&0  '$ ?$  '*I&1  ' (*I&2 2 2(' b?'  0 @ 2 '0,'3  '' E? b'  '0,'4  '$ ?E$  '0,'5  '$ ?$  '0,'6  ' (0,'7 2 2(' b?'  0 @ 3 'g-(8  '' E? b'  'g-(9  '$ ?E$  'g-(:  '$ ?$  'g-(;  '_ (g-(< 2 2(' b?'  0 @ 4 '2  '' E? b'  '2  '$ ?E$  '2  '$ ?$  '2  ' (2 2 2(' b?'  0 @ 5 'i  '' E? b'  'i  '$ ?E$  'i  '$ ?$  'i   ' (i  2 2(' b?'  0 @ 6 'P   '' E? b'  'P   '$ ?E$  'P   '$ ?$  'P  'P 2  $ ?$*?*0   _Ic_.  OTHERINFORMATION- }(#(# 3V?30   V   HUSBAND ?   WIFE A(#(# StreetAddress(mailingifdifferent) V _________________ ? _________________  -  City,State,Zip(mailingifdifferent) V _________________ ? _________________   Hometelephonenumber V _________________ ? _________________   Driver'slicensenumberandState V _________________ ? _________________   Employer'sname V _________________ ? _________________ y  Employer'sstreetaddress V _________________ ? _________________ e Employer'sCity,State,Zip V _________________ ? _________________ Q Employer'stelephonenumber V _________________ ? _________________ = - V?X-  0   II.  EXPENSES(Youmayelecttolistallexpensesonaweeklybasisorallexpensesona Q  monthlybasis;however,youmustbeconsistent.Ifanyitemsarepaidonamonthlybasis, =! divideby4.3toobtainweeklypayments;ifanyitemsarepaidonaweeklybasis,multiplyby )" 4.3toobtainmonthlypayment.Attachadditionalsheet,ifneeded.Itemsincludedunder #  Othershouldbelistedseparatelywithseparatedollaramounts.)$(#(# d='z X'0  Expenseslisted z []weekly  []monthly=&(#(# 6< z F6  (a)  Housing  ) 1.  Rent < ______  4.  Condominiumcharges  ______ !* 2.  Mortgageandamortization < ______  5.  Cooperativeapartment "+ 3.  Realestatetaxes < ______    maintenance  ______ u#, d%!M% E <: <E   < Total:Housing    $______ %!. (b)  Utilities u(#1 1.  Fueloil < ______  4.  Telephone  ______ a)$2 2.  Gas < ______  5.  Water  ______ M*%3 3.  Electricity < ______ 9+&4 du-(-a(   < Total:Utilities    $______ u-(6 Ї_(c_)  Food  1.  Groceries < ______  5.  Liquor/alcohol  ______  2.  Schoollunches < ______  6.  Homeentertainment  ______ t 3.  Lunchesatwork < ______  7.  Other  ______ ` 4.  Diningout < ______ L  d $ t   < Total:Food    0  $______ (#(# (d)  Clothing L  1.  Husband < ______  3.  Children  ______ 8  2.  Wife < ______  4.  Other:_______  ______ $t  d` L    < Total:Clothing    $______ `  (e)  Laundry $t 1.  Laundryathome < ______  3.  Other________ ` 2.  Drycleaning < ______ L d8$   < Total:Laundry    $______ 8 (f)  Insurance L 1.  Life < ______  7.  Dentalplan  ______ 8 2.  Homeowners/tenants < ______  8.  Opticalplan  ______ $ 3.  Fire,theftandliability < ______  9.  Disability  ______  H < ' <: H4.  Automotive < ______  10.WorkersCompensation  ______  H < (# < H5.  Umbrellapolicy < ______  11.Other_____  ______   6.  Medicalplan < ______ ! d#\#H <:  < XH   < Total:Insurance    $______ #  (g)  _Unreimbursed_Ԁmedical &!# 1.  Medical < ______  4.  Pharmaceutical  ______ p'"$ 2.  Dental < ______  5.  Surgical,nursing,hospital  ______ \(#% 3.  Optical < ______  6.  Other____________  ______ H)$& d+& +p&  Total:_Unreimbursed_ԀMedical      $______ +&(  \-(* (h)  Householdmaintenance  1.  Repairs < ______  5.  Painting  ______  2.  Furniture,furnishings, <   6.  Sanitation/carting  ______    housewares < ______  7.  Gardening/landscaping  ______ t 3.  Cleaningsupplies <   8.  Snowremoval  ______ ` H < % <: H4.  Appliances,including <   9.  Extermination  ______ L    maintenance < ______  10  Other_________  ______ 8  dt  `H <:  < H  Total:HouseholdMaintenance      $______ t  (_i_)  Householdhelp 8  1.  Babysitter < ______  3.  Other____________  ______ $t  2.  Domestic `    (housekeeper,maid,etc.) < ______ L  d8$   < Total:HouseholdHelp  $______ 8 B<  <: B(j)  Automotive L d8$9 ?< 9Year________ Make___________________  Personal[] ? Business[] 8 dt`Year________ Make___________________  Personal[] ? Business[] t dLYear________ Make:___________________  Personal[] ? Business[]  d<<<  <1.  Payments < ______  5.  Registrationandlicense  ______ < 2.  Gasandoil < ______  6.  Parkingandtolls  ______  ( 3.  Repairs < ______  7.  Other_____________  ______ ! 4.  Carwash < ______ " B<: <B   < _Total:_ԀAutomotive  $______ # B< <XB(k)  Educational `&!" 1.  Nurseryandpre-school < ______  6.  Schooltransportation  ______ L'"# 2.  Primaryandsecondary < ______  7.  Schoolsupplies/books  ______ 8(#$ 3.  College < ______  8.  Tutoring  ______ $)t$% 4.  Post-graduate < ______  9.  Schoolevents  ______ *`%& 5.  Religiousinstruction < ______  10  Other__________  ______ *L&' d8-(,$(B<: <B   < Total:Educational  $______ 8-() ЇB< <XB(l)  Recreational  1.  Summercamp < ______  9.  Countryclub/poolclub  ______  E < (#<E2.  Vacations < ______  10.Healthclub  ______ t 3.  Movies < ______  11.Sportinggoods  ______ ` 4.  Theater,ballet,etc. < ______  12.Hobbies  ______ L  H < % < XH5.  Videorentals < ______  13.Music/dancelessons  ______ 8  H < (# < H6.  Tapes,CDs,etc. < ______  14.Sportslessons  ______ $ t H < % < XH7.  Cabletelevision < ______  15.Birthdayparties  ______  ` 8.  Teamsports < ______  16.Other:__________  ______  L  d8 $ E<:  < E   < Total:Recreational  $______ 8  B< <XB(m)Incometaxes L  1.  Federal < ______  3.  City  ______ 8 2.  State < ______  4.  SocialSecurityand $    <     Medicare  ______  dLB<: <B   < Total:IncomeTaxes  $______ L B< <XB(n)  Miscellaneous  1.  Beautyparlor/barber < ______  9.  Union/organizationdues  ______  H" < %'<H2.  Beautyaids/cosmetics, <   10.Commutation/transp.  ______    drugitems < ______  11.Veterinarian/petexpenses  ______  3.  Cigarettes/tobacco < ______  12.Childsupportpayments p 4.  Books,magazines, <     (priormarriage)  ______ \   newspapers < ______  13.Alimonyandmaintenance H 5.  Childrensallowances < ______    payments(priormarriage)  ______ 4  6.  Gifts < ______  14.Loanpayments  ______  !p 7.  Charitablecontributions < ______  15._Unreimbursed_Ԁbusiness  "\ 8.  Religiousorganizationdues < ___0  0(#(#expenses  ______"H (#(# d4% $ H<:  < %XH   < Total:Miscellaneous  $______ 4% " B< <XB(o)  Other 'H#% 1.  ________________ < ______  3.  ________________  ______ (4$& 2.  ________________ < ______  4.  ________________  ______ ) %' B<: <B   < Total:Other  0    $______,'*(#(#  -(+ Ї<: <X< 0  TOTALEXPENSES       $______XX(#(# XX- xX-  0 x  III. x GROSSINCOME(Statesourceofincomeandannualamount.Attachadditionalsheet,if x needed.)dx(#x(# 'x'  0 x 0x(#x(#  x (a)  Salaryorwages:(Statewhetherincomehaschangedduringtheyearprecedingdate P  ofthisaffidavit_______.Ifso,setforthnameandaddressofallemployersduring <  precedingyearandaverageweeklywagepaidbyeach.Indicateovertimeearnings ( x separately.AttachpreviousyearsW-2orincometaxreturn.) d(#(# * x*0   _______________________________________________________ P (#(# 0  _______________________________________________________ < (#(# 0x x00 x 0x(#x(#  x (b)  Weeklydeductions:( (#(# 3 x 30   1. Federaltax  _____ (#(# 0   2. NewYorkStatetax  _____ (#(# 0   3. Localtax  _____ (#(# 0   4. SocialSecurity  _____ (#(# 0   5. Medicare  _____t(#(# 0  6. Otherpayrolldeductions(specify)  _____`(#(# 0r x 00 r 0r(#r(# r _(c_)  SocialSecuritynumber_____________________L(#(# 0 r 0r(#r(# r (d)  Numberandnamesofdependentsclaimed_______________8(#(# 0r r 00 r 0r(#r(# r (e)  Bonus,commissions,fringebenefits$t(#(# (useofauto,memberships,etc.)  _____ ` 0 r 0r(#r(# r (f)  Partnership,royalties,saleofassets(incomeandL(#(# installmentpayments)  _____ 8 0 r 0r(#r(# r (g)  Dividendsandinterest(statewhethertaxableornot)  _____$(#(# 0 r 0r(#r(# r (h)  Realestate(incomeonly)  _____(#(# 0 r 0r(#r(# r (_i_)  Trust,profit-sharingandannuities(#(# (principaldistributionandincome)  _____  0 r 0r(#r(# r (j)  Pension(incomeonly)  _____(#(# 0 r 0r(#r(# r (k)  Awards,prizes,grants(statewhethertaxable)  _____p(#(# 0 r 0r(#r(# r (l)  Bequests,legaciesandgifts  _____\ (#(# 0xr00 x 0x(#x(#  x (m)  Incomefromallothersources  _____H!(#(# 0 x 0x(#x(#(includingalimony,maintenance,childsupport4" (#(# frompriormarriage)  #p! 0 x 0x(#x(#  x (n)  Taxpreferenceitems: $\"(#(# 0 x00   1. Long-termcapitalgaindeduction  _____$H #(#(# 0   2. Depreciation,amortizationordepletion  _____%4!$(#(# 0   00  3. Stockoptions(excessoffairmarketvalueoveramountpaid)  _____& "%(#(# -r -0 r 0r(#r(# r (o)  Ifanychildorothermemberofyourhouseholdisemployed,' #&(#(# setforthnameandthatpersonsannualincome  _____ (#' 0 r 0r(#r(# r (p)  SocialSecurity  _____)$((#(# 0 r 0r(#r(# r (q)  Disabilitybenefits  _____*%)(#(# 0 r 0r(#r(# r _(r_)  Publicassistance  _____l+&*(#(# -xr-0 x 0x(#x(#  x (s)  Other  _____X,'+(#(#  D-(, dd * ,x*0  TOTALINCOME0(#(# $_____d(#(# $ ,$  0   IV.  ASSETS(Ifanyassetisheldjointlywithspouseoranother,sostate,andsetforthyour , respectiveshares.Attachadditionalsheets,ifneeded.)(#(# A.  CashAccounts     Cash   ' X'  0  0(#(#  1.1  a. Location________________________________________ (#(# 0  0(#(#b. Sourceoffunds___________________________________x (#(# - : &-0  c. Amount  $_____d  (#(# -  X-0    Total:Cash $_____P (#(# d (x ' '    CheckingAccounts   * X*  0  0(#(#  2.1  a. Financialinstitution  ______________________________x (#(# 0  0(#(#b. Accountnumber_________________________________d (#(# 0  0(#(#c. Titleholder_____________________________________P(#(# 0  0(#(#d. Dateopened____________________________________<(#(# 0  0(#(#e. Sourceoffunds__________________________________(x(#(# -  -0  f. Balance  $_____d(#(# dP<*  *0  0(#(#  2.2  a. Financialinstitution_______________________________P(#(# 0  0(#(#b. Accountnumber__________________________________<(#(# 0  0(#(#c. Titleholder______________________________________(x(#(# 0  0(#(#d. Dateopened_____________________________________d(#(# 0  0(#(#e. Sourceoffunds___________________________________P(#(# * &*0  f. Balance  $_____<(#(# *  *0    Total:Checking $_____((#(# d d' '  Savingaccounts(includingindividual,joint,Tottentrust  d   certificatesofdeposit,treasurynotes) !P * X*0  0(#(#  3.1  a. Financialinstitution_______________________________!<(#(# 0  0(#(#b. Accountnumber__________________________________"((#(# 0  0(#(#c. Titleholder______________________________________# (#(# 0  0(#(#d. Typeofaccount__________________________________$ !(#(# 0  0(#(#e. Dateopened_____________________________________% "(#(# 0  0(#(#f. Sourceoffunds___________________________________&!#(#(# -  -0  g. Balance  $_____t'"$(#(# d)%L)$-  -0  0(#(#  3.2  a. Financialinstitution_______________________________)%&(#(# 0  0(#(#b. Accountnumber__________________________________*%'(#(# 0  0(#(#c. Titleholder______________________________________+&((#(# 0  0(#(#d. Typeofaccount__________________________________t,')(#(# 0  0(#(#e. Dateopened_____________________________________`-(*(#(# _0  0(#(#f. Sourceoffunds___________________________________(#(# -  -0  g. Balance  $_____(#(# *  *0    Total:Savings $_____(#(# d`' '    Securitydeposits,earnestmoney,etc.  * X*  0  0(#(#  4.1  a. Location_________________________________________ (#(# 0  0(#(#b. Titleowner_______________________________________ (#(# 0  0(#(#c. Typeofdeposit___________________________________ (#(# 0  0(#(#d. Sourceoffunds____________________________________t (#(# 0  0(#(#e. Dateofdeposit____________________________________`  (#(# -  -0  f. Amount  $_____L (#(# *  *0    Total:SecurityDeposits,etc. $_____8 (#(# dt ` ' '    Other t  ' X'  0  0(#(#  5.1  a. Location_________________________________________` (#(# 0  0(#(#b. Titleowner_______________________________________L(#(# 0  0(#(#c. Typeofaccount___________________________________8(#(# 0  0(#(#d. Sourceoffunds____________________________________$t(#(# 0  0(#(#e. Dateofdeposit____________________________________`(#(# * &*0  f. Amount  $_____L(#(# *  *0    Total:Other $_____8(#(# d$t* *    TOTAL:CashAccounts $_____ $t $ $B.  Securities 8   Bonds,notes,mortgages $ ' X'  0  0(#(#  1.1  a. Descriptionofsecurity_____________________________(#(# * &*0  b. Titleholder______________________________________(#(# 0  c. Location________________________________________ (#(# 0  d. Dateofacquisition________________________________!(#(# 0  e. Originalpriceorvalue______________________________p"(#(# 0  f. Sourceoffundstoacquire___________________________\# (#(# *  *0  g. Currentvalue  $_____H$!(#(# *  *0    Total:Bonds,Notes,etc. $_____4% "(#(# dp'" '\"' '    Stocks,optionsandcommoditycontracts p'"$ ' X'  0  0(#(#  2.1  a. Descriptionofsecurity_____________________________\(#%(#(# 0  0(#(#b. Titleholder______________________________________H)$&(#(# 0  0(#(#c. Location________________________________________4*%'(#(# 0  0(#(#d. Dateofacquisition________________________________ +p&((#(# 0  0(#(#e. Originalpriceorvalue______________________________ ,\')(#(# 0  0(#(#f. Sourceoffundstoacquire___________________________,H(*(#(# * &*0  g. Currentvalue  $_____-4)+(#(# Їdd-  -0  0(#(#  2.2  a. Descriptionofsecurity_____________________________d(#(# 0  0(#(#b. Titleholder______________________________________P(#(# 0  0(#(#c. Location________________________________________<(#(# 0  0(#(#d. Dateofacquisition________________________________((#(# 0  0(#(#e. Originalpriceorvalue______________________________(#(# 0  0(#(#f. Sourceoffundstoacquire___________________________ (#(# 0  0(#(#g. Currentvalue  $_____ (#(# d (t 0  0(#(#  2.3  a. Descriptionofsecurity_____________________________ ((#(# 0  0(#(#b. Titleholder______________________________________  (#(# 0  0(#(#c. Location________________________________________ (#(# 0  0(#(#d. Dateofacquisition________________________________ (#(# 0  0(#(#e. Originalpriceorvalue______________________________ (#(# 0  0(#(#f. Sourceoffundstoacquire__________________________t (#(# 0  0(#(#g. Currentvalue  $_____` (#(# -  -0    Total:Stocks,Options,etc. $_____L(#(# d$t' '    Brokermarginaccounts  ' X'  0  0(#(#  3.1  a. Nameandaddressofbroker_________________________t(#(# 0  0(#(#b. Titleholder____________________________________`(#(# 0  0(#(#c. Dateaccountopened_____________________________L(#(# 0  0(#(#d. Originalvalueofaccount__________________________8(#(# 0  0(#(#e. Sourceoffunds__________________________________$t(#(# * &*0  f. Currentvalue  $_____`(#(# *  *0    Total:MarginAccount $_____L(#(# d8$- -      TOTAL:ValueofSecurities $_____ 8 C.  LoanstoOthersandAccountsReceivable !8 - -  0  0(#(#  1.1  a. Debtorsnameandaddress________________________"$(#(# 0  0(#(#b. Originalamountofloanordebt_____________________# (#(# 0  0(#(#c. Sourceoffundsfromwhichloanmadeororiginofdebt$!(#(# 0  0(#(# ______________________________________________% "(#(# 0  0(#(#d. Datepayment(s)due_____________________________&!#(#(# * &*0  e. Currentamountdue  $_____p'"$(#(# d)$H)$-  -0  0(#(#  1.2  a. Debtorsnameandaddress_________________________)$&(#(# 0  0(#(#b. Originalamountofloanordebt______________________*%'(#(# 0  0(#(#c. Sourceoffundsfromwhichloanmadeororiginofdebt+&((#(# 0  0(#(# _______________________________________________p,')(#(# 0  0(#(#d. Datepayment(s)due_______________________________\-(*(#(# 0  0(#(#e. Currentamountdue  $_____(#(# d<-  -0    TOTAL:LoansandAccountsReceivable_$______<(#(# ' '  D.  ValueofInterestinAnyBusiness   ' X'  0  0(#(#  1.1  a. Nameandaddressofbusiness______________________ (#(# 0  0(#(# _______________________________________________ (#(# 0  0(#(#b. Typeofbusiness(corporate,partnership,solet (#(# 0  0(#(# proprietorshiporother)___________________________`  (#(# 0  0(#(#c. Yourcapitalcontribution__________________________L (#(# 0  0(#(#d. Yourpercentageofinterest_________________________8 (#(# 0  0(#(#e. Dateofacquisition_______________________________$t (#(# 0  0(#(#f. Originalpriceorvalue_____________________________` (#(# 0  0(#(#g. Sourceoffundstoacquire__________________________L (#(# 0  0(#(#h. Methodofvaluation_______________________________8(#(# 0  0(#(#_i_. Otherrelevantinformation__________________________$(#(# * &*0  j. Currentnetworthofbusiness  $_____(#(# dL*:  *0    TOTAL:ValueofBusinessInterest : $_____L(#(# ' <'  E.  CashSurrenderValueofLifeInsurance  ' X'  0  0(#(#  1.1  a. Insurersnameandaddress_________________________(#(# 0  0(#(# _______________________________________________(#(# 0  0(#(#b. Nameofinsured_________________________________(#(# 0  0(#(#c. Policynumber___________________________________p(#(# 0  0(#(#d. Faceamountofpolicy_____________________________\(#(# 0  0(#(#e. Policyowner_____________________________________H(#(# 0  0(#(#f. Dateofacquisition________________________________4 (#(# * &*0  g. Sourceoffundingtoacquire_________________________ !p(#(# d\#"H0  h. Currentcashsurrendervalue  $_____\# (#(# d% 4% **:  *0   * TOTAL:ValueofLifeInsurance : $_____% "(#(# ' *'  F.  Vehicles(automobile,boat,plane,truck,camper,etc.) \(#% ' X'  0  0(#(#  1.1  a. Description_______________________________________H)$&(#(# 0  0(#(#b. Titleowner_______________________________________4*%'(#(# 0  0(#(#c. Dateofacquisition_________________________________ +p&((#(# 0  0(#(#d. Originalprice_____________________________________ ,\')(#(# 0  0(#(#e. Sourceoffundstoacquire___________________________,H(*(#(# 0  0(#(#f. Amountofcurrentlienpaid__________________________-4)+(#(# _* &*0  g. Currentfairmarketvalue  $_____(#(# d<*  *0  0(#(#  1.2  a. Description_______________________________________<(#(# 0  0(#(#b. Titleowner_______________________________________((#(# 0  0(#(#c. Dateofacquisition_________________________________(#(# 0  0(#(#d. Originalprice_____________________________________ (#(# 0  0(#(#e. Sourceoffundstoacquire___________________________ (#(# 0  0(#(#f. Amountofcurrentlienunpaid________________________ (#(# * &*0  g. Currentfairmarketvalue  $_____t (#(# d L *:  *0    TOTAL:ValueofVehicles : $_____ (#(# ' z '0   G.  RealEstate(includingrealproperty,leaseholds,lifeestates,etc.att (#(# marketvalue"donotdeductanymortgage) `  ' X'0  0(#(#  1.1  a. Description_______________________________________L(#(# 0  0(#(#b. Titleowner_______________________________________8(#(# 0  0(#(#c. Dateofacquisition_________________________________$t(#(# 0  0(#(#d. Originalprice_____________________________________`(#(# 0  0(#(#e. Sourceoffundstoacquire___________________________L(#(# 0  0(#(#f. Amountofmortgageorlienunpaid____________________8(#(# * &*0  g. Estimatedcurrentmarketvalue  $_____$(#(# d`*  *0  0(#(#  1.2  a. Description_______________________________________`(#(# 0  0(#(#b. Titleowner_______________________________________L(#(# 0  0(#(#c. Dateofacquisition_________________________________8(#(# 0  0(#(#d. Originalprice______________________________________$(#(# 0  0(#(#e. Sourceoffundstoacquire____________________________(#(# 0  0(#(#f. Amountofmortgageorlienunpaid_____________________(#(# * &*0  g. Estimatedcurrentmarketvalue  $_____ (#(# d"$p"*  *0  0(#(#  1.3  a. Description________________________________________"$(#(# 0  0(#(#b. Titleowner________________________________________# (#(# 0  0(#(#c. Dateofacquisition__________________________________$!(#(# 0  0(#(#d. Originalprice______________________________________% "(#(# 0  0(#(#e. Sourceoffundstoacquire____________________________&!#(#(# 0  0(#(#f. Amountofmortgageorlienunpaid_____________________p'"$(#(# * &*0  g. Estimatedcurrentmarketvalue  $_____\(#%(#(# d*%4*%*  *    TOTAL:ValueofRealEstate $_____ *%' $ $  0   H.  VestedInterestsinTrusts(pension,profit-sharing,legacies,deferred\-(*(#(# compensationandothers)  ' X'0  0(#(#  1.1  a. Descriptionoftrust________________________________(#(# 0  0(#(#b. Locationofassets_________________________________(#(# 0  0(#(#c. Titleowner______________________________________t(#(# 0  0(#(#d. Dateofacquisition________________________________`(#(# 0  0(#(#e. Originalinvestment________________________________L (#(# 0  0(#(#f. Sourceoffunds___________________________________8 (#(# 0  0(#(#g. Amountofunpaidliens_____________________________$ t(#(# * &*0  h. Currentvalue  $_____ `(#(# dL 8 *  *0  0(#(#  1.2  a. Descriptionoftrust________________________________L (#(# 0  0(#(#b. Locationofassets_________________________________8 (#(# 0  0(#(#c. Titleowner______________________________________$t (#(# 0  0(#(#d. Dateofacquisition________________________________` (#(# 0  0(#(#e. Originalinvestment________________________________L (#(# 0  0(#(#f. Sourceoffunds___________________________________8(#(# 0  0(#(#g. Amountofunpaidliens_____________________________$(#(# * &*0  h. Currentvalue  $_____(#(# dL*  *0    TOTAL:VestedInterestinTrusts $_____L(#(# $  $0   I.  ContingentInterests(stockoptions,interestssubjecttolifeestates,(#(# prospectiveinheritances,etc.)  ' X'0  0(#(#  1.1  a. Description______________________________________(#(# 0  0(#(#b. Location_________________________________________(#(# 0  0(#(#c. Dateofvesting____________________________________p(#(# 0  0(#(#d. Titleowner_______________________________________\(#(# 0  0(#(#e. Dateofacquisition_________________________________H(#(# 0  0(#(#f. Originalpriceorvalue_______________________________4 (#(# 0  0(#(#g. Sourceoffundstoacquire____________________________ !p(#(# 0  0(#(#h. Methodofvaluation________________________________ "\(#(# * &*0  i. Currentvalue  $_____"H (#(# d4% $ *  *0    TOTAL:ContingentInterests $_____4% "(#(# ' '  J.  HouseholdFurnishings 'H#% ' X'  0  0(#(#  1.1  a. Description_______________________________________(4$&(#(# 0  0(#(#b. Location_________________________________________) %'(#(# 0  0(#(#c. Titleowner_______________________________________* &((#(# 0  0(#(#d. Originalprice______________________________________+&)(#(# 0  0(#(#e. Sourceoffundstoacquire____________________________,'*(#(# 0  0(#(#f. Amountoflienunpaid_______________________________-(+(#(# * &*0  g. Currentvalue  $_____(#(# d<*:  *0    TOTAL:HouseholdFurnishings : $_____<(#(# ' z '0   K.  Jewelry,Art,Antiques,PreciousObjects,GoldandPreciousMetals (#(# (onlyifvaluedatmorethan$500)   ' X'0  0(#(#  1.1  a. Description________________________________________ (#(# 0  0(#(#b. Titleowner________________________________________t (#(# 0  0(#(#c. Location__________________________________________`  (#(# 0  0(#(#d. Originalpriceorvalue_______________________________L (#(# 0  0(#(#e. Sourceoffundstoacquire____________________________8 (#(# 0  0(#(#f. Amountoflienunpaid_______________________________$t (#(# * &*0  g. Currentvalue  $_____` (#(# dL8*  *0  0(#(#  1.2  a. Description________________________________________L(#(# 0  0(#(#b. Titleowner________________________________________8(#(# 0  0(#(#c. Location__________________________________________$t(#(# 0  0(#(#d. Originalpriceorvalue_______________________________`(#(# 0  0(#(#e. Sourceoffundstoacquire____________________________L(#(# 0  0(#(#f. Amountoflienunpaid_______________________________8(#(# * &*0  g. Currentvalue  $_____$(#(# d`*  *0    TOTAL:Jewelry,Art,etc. $_____`(#(# ' '0   L.  Other(e.g.,taxshelterinvestments,collections,judgments,causes$(#(# ofaction,patents,trademarks,copyrights,andanyotherassetnot  hereinaboveitemized)  ' X'0  0(#(#  1.1  a. Description______________________________________ (#(# 0  0(#(#b. Titleowner______________________________________!(#(# 0  0(#(#c. Location________________________________________p"(#(# 0  0(#(#d. Originalpriceorvalue______________________________\# (#(# 0  0(#(#e. Sourceoffundstoacquire___________________________H$!(#(# 0  0(#(#f. Amountoflienunpaid______________________________4% "(#(# * &*0  g. Currentvalue  $_____ &p!#(#(# d\(#'H#*  *0  0(#(#  1.2  a. Description_______________________________________\(#%(#(# 0  0(#(#b. Titleowner_______________________________________H)$&(#(# 0  0(#(#c. Location_________________________________________4*%'(#(# 0  0(#(#d. Originalpriceorvalue______________________________ +p&((#(# 0  0(#(#e. Sourceoffundstoacquire___________________________ ,\')(#(# 0  0(#(#f. Amountoflienunpaid______________________________,H(*(#(# * &*0  g. Currentvalue  $_____-4)+(#(# Їdd*:  *0    TOTAL:Other : $_____d(#(# dP<' : z ' 0  TOTALASSETS  : $_____P(#(# $ p$  V.  LIABILITIES  h A.  AccountsPayable  T ' X'  0  0(#(#  1.1  a. Nameandaddressofcreditor_______________________ @(#(# 0  0(#(#b. Debtor_________________________________________ ,(#(# 0  0(#(#c. Amountoforiginaldebt____________________________  (#(# 0  0(#(#d. Dateofincurringdebt______________________________ (#(# 0  0(#(#e. Purpose_________________________________________ (#(# 0  0(#(#f. Monthlyorotherperiodicpayment___________________ (#(# * &*0  g. Amountofcurrentdebt  $_____x (#(# dP*  *0  0(#(#  1.2  a. Nameandaddressofcreditor________________________(#(# 0  0(#(#b. Debtor_________________________________________(#(# 0  0(#(#c. Amountoforiginaldebt____________________________x(#(# 0  0(#(#d. Dateofincurringdebt______________________________d(#(# 0  0(#(#e. Purpose_________________________________________P(#(# 0  0(#(#f. Monthlyorotherperiodicpayment___________________<(#(# * &*0  g. Amountofcurrentdebt  $_____(x(#(# ddP*  *0  0(#(#  1.3  a. Nameandaddressofcreditor_________________________d(#(# 0  0(#(#b. Debtor___________________________________________P(#(# 0  0(#(#c. Amountoforiginaldebt_____________________________<(#(# 0  0(#(#d. Dateofincurringdebt_______________________________(x(#(# 0  0(#(#e. Purpose__________________________________________ d(#(# 0  0(#(#f. Monthlyorotherperiodicpayment____________________!P(#(# * &*0  g. Amountofcurrentdebt  $_____!<(#(# d($x#*  *0  0(#(#  1.4  a. Nameandaddressofcreditor_________________________($x (#(# 0  0(#(#b. Debtor___________________________________________%d !(#(# 0  0(#(#c. Amountoforiginaldebt______________________________&P!"(#(# 0  0(#(#d. Dateofincurringdebt_______________________________&<"#(#(# 0  0(#(#e. Purpose__________________________________________'(#$(#(# 0  0(#(#f. Monthlyorotherperiodicpayment____________________($%(#(# * &*0  g. Amountofcurrentdebt  $_____)%&(#(# d+<'+&*  *0  0(#(#  1.5  a. Nameandaddressofcreditor_________________________+<'((#(# 0  0(#(#b. Debtor___________________________________________,(()(#(# 0  0(#(#c. Amountoforiginaldebt_____________________________-)*(#(# 0  0(#(#d. Dateofincurringdebt_______________________________(#(# 0  0(#(#e. Purpose__________________________________________(#(# 0  0(#(#f. Monthlyorotherperiodicpayment____________________(#(# * &*0  g. Amountofcurrentdebt  $_____t(#(# d L *  *0    TOTAL:AccountsPayable $_____ (#(# ' '  B.  NotesPayable t  ' X'  0  0(#(#  1.1  a. Nameandaddressofnoteholder______________________`  (#(# 0  0(#(#b. Debtor___________________________________________L (#(# 0  0(#(#c. Amountoforiginaldebt_____________________________8 (#(# 0  0(#(#d. Dateofincurringdebt_______________________________$t (#(# 0  0(#(#e. Purpose__________________________________________` (#(# 0  0(#(#f. Monthlyorotherperiodicpayment____________________L (#(# * &*0  g. Amountofcurrentdebt  $_____8(#(# d$t*  *0  0(#(#  1.2  a. Nameandaddressofnoteholder______________________$t(#(# 0  0(#(#b. Debtor___________________________________________`(#(# 0  0(#(#c. Amountoforiginaldebt_____________________________L(#(# 0  0(#(#d. Dateofincurringdebt_______________________________8(#(# 0  0(#(#e. Purpose__________________________________________$(#(# 0  0(#(#f. Monthlyorotherperiodicpayment____________________(#(# * &*0  g. Amountofcurrentdebt  $_____(#(# d8*  *0    TOTAL:NotesPayable $_____8(#(# ' '  C.  InstallmentAccountsPayable(securityagreements,chattelmortgages)  ' X'  0  0(#(#  1.1  a. Nameandaddressofcreditor_________________________ (#(# 0  0(#(#b. Debtor___________________________________________!(#(# 0  0(#(#c. Amountoforiginaldebt_____________________________p"(#(# 0  0(#(#d. Dateofincurringdebt_______________________________\# (#(# 0  0(#(#e. Purpose__________________________________________H$!(#(# 0  0(#(#f. Monthlyorotherperiodicpayment____________________4% "(#(# * &*0  g. Amountofcurrentdebt  $_____ &p!#(#(# d\(#'H#*  *0  0(#(#  1.2  a. Nameandaddressofcreditor_________________________\(#%(#(# 0  0(#(#b. Debtor___________________________________________H)$&(#(# 0  0(#(#c. Amountoforiginaldebt_____________________________4*%'(#(# 0  0(#(#d. Dateofincurringdebt_______________________________ +p&((#(# 0  0(#(#e. Purpose__________________________________________ ,\')(#(# 0  0(#(#f. Monthlyorotherperiodicpayment____________________,H(*(#(# * &*0  g. Amountofcurrentdebt  $_____-4)+(#(# Їdd*  *0    TOTAL:InstallmentAccounts $_____d(#(# ' '  D.  BrokersMarginAccounts ( ' X'  0  0(#(#  1.1  a. Nameandaddressofbroker__________________________(#(# 0  0(#(#b. Amountoforiginaldebt_____________________________ (#(# 0  0(#(#c. Dateofincurringdebt_______________________________ (#(# 0  0(#(#d. Purpose__________________________________________ (#(# 0  0(#(#e. Monthlyorotherperiodicpayment____________________t (#(# * &*0  f. Amountofcurrentdebt  $_____`  (#(# d 8 *  *0    TOTAL:BrokersMarginAccount $_____ (#(# $  $  E.  MortgagesPayableonRealEstate `  ' X'  0  0(#(#  1.1  a. Nameandaddressofmortgagee_______________________L(#(# 0  0(#(#b. Addressofpropertymortgaged_______________________8(#(# 0  0(#(#c. Mortgagor(s)______________________________________$t(#(# 0  0(#(#d. Originaldebt______________________________________`(#(# 0  0(#(#e. Dateofincurringdebt_______________________________L(#(# 0  0(#(#f. Monthlyorotherperiodicpayment____________________8(#(# 0  0(#(#g. Maturitydate_____________________________________$(#(# * &*0  h. Amountofcurrentdebt  $_____(#(# dL*  *0  0(#(#  1.2  a. Nameandaddressofmortgagee_______________________L(#(# 0  0(#(#b. Addressofpropertymortgaged_______________________8(#(# 0  0(#(#c. Mortgagor(s)______________________________________$(#(# 0  0(#(#d. Originaldebt______________________________________(#(# 0  0(#(#e. Dateofincurringdebt_______________________________(#(# 0  0(#(#f. Monthlyorotherperiodicpayment____________________ (#(# 0  0(#(#g. Maturitydate_____________________________________!(#(# * &*0  h. Amountofcurrentdebt  $_____p"(#(# d$H$*  *0    TOTAL:MortgagesPayable $_____$!(#(# ' '  F.  TaxesPayable p'"$ ' X'  0  0(#(#  1.1  a. Descriptionoftax__________________________________\(#%(#(# 0  0(#(#b. Amountoftax_____________________________________H)$&(#(# 0  0(#(#c. Datedue_________________________________________4*%'(#(# dp,' ,\'* &*0    TOTAL:TaxesPayable $_____p,')(#(#  \-(* Ї' '  G.  LoansonLifeInsurancePolicies  ' X'  0  0(#(#  1.1  a. Nameandaddressofinsurer__________________________(#(# 0  0(#(#b. Amountofloan____________________________________(#(# 0  0(#(#c. Dateincurred______________________________________t(#(# 0  0(#(#d. Purpose__________________________________________`(#(# 0  0(#(#e. Nameofborrower__________________________________L (#(# 0  0(#(#f. Monthlyorotherperiodicpayment____________________8 (#(# * &*0  g. Amountofcurrentdebt  $_____$ t(#(# d`  L*  *0    TOTAL:LifeInsuranceLoans $_____`  (#(# ' '  H.  OtherLiabilities $t  ' X'  0  0(#(#  1.1  a. Description______________________________________` (#(# 0  0(#(#b. Nameandaddressofcreditor________________________L (#(# 0  0(#(#c. Debtor__________________________________________8(#(# 0  0(#(#d. Originalamountofdebt____________________________$(#(# 0  0(#(#e. Dateincurred____________________________________(#(# 0  0(#(#f. Purpose________________________________________(#(# 0  0(#(#g. Monthlyorotherperiodicpayment__________________(#(# * &*0  h. Amountofcurrentdebt  $_____(#(# d\*  *0  0(#(#  1.2  a. Description______________________________________(#(# 0  0(#(#b. Nameandaddressofcreditor________________________(#(# 0  0(#(#c. Debtor__________________________________________(#(# 0  0(#(#d. Originalamountofdebt____________________________(#(# 0  0(#(#e. Dateincurred____________________________________p(#(# 0  0(#(#f. Purpose________________________________________\(#(# 0  0(#(#g. Monthlyorotherperiodicpayment__________________H(#(# * &*0  h. Amountofcurrentdebt  $_____4 (#(# dp" "\*  *0    TOTAL:OtherLiabilities $_____p"(#(# d$H$'  '0  TOTALLIABILITIES  $_____$!(#(# ! !  NETWORTH  `(#% ! !  0  TOTALASSETS:  $____________$+t&(   d`-(,L(*V}*0  TOTALLIABILITIES: V (minus) } ($____________)`-(*   de0  NETWORTH: V  }   $____________e   * V}K*0   VI.  ASSETSTRANSFERRED(Listallassetstransferredinanymannerduringthepreceding > threeyears,orlengthofthemarriage,whicheverisshorter[transfersintheroutinecourse * ofbusinesswhichresultedinanexchangeofassetsofsubstantiallyequivalentvalueneed  notbespecificallydisclosedwheresuchassetsareotherwiseidentifiedinthestatementof  networth])(#(# *z 2X*  Description z ToWhomTransferred 2 Dateof b  ofProperty z andRelationshiptoTransferee 2 Transfer  Value N  ___________________ z __________________________ 2 ___________  ________ :   dv b ___________________ z __________________________ 2 ___________  ________ v  d N ___________________ z __________________________ 2 ___________  ________   d>___________________ z __________________________ 2 ___________  ________ > d*z___________________ z __________________________ 2 ___________  ________ *z dfR___________________ z __________________________ 2 ___________  ________ f * z 2r*VII.  SUPPORTREQUIREMENTS *z dfR'<@X'  0 <  (a) < Deponentisatpresent[paying/receiving]$_________per[week/month],andpriorto f separation[paid/received]$______per[week/month]tocoverexpensesfor__________ R ______________________________________________________________________. > Thesepaymentsarebeingmade[voluntarily/pursuanttocourtorderorjudgment/ * z pursuanttoseparationagreement],andthereare[no]arrearsoutstanding[inthesumof !f $________todate]."R<(#<(# d>$#*0 <  (b) < Deponentrequestsforsupportofeachchild$________per[week/month].Totalfor >$ children$________.*%z <(#<(# df'"'R"0 <  (c) < Deponentrequestsforsupportofself$________per[week/month].f'""<(#<(# d)$>)$0 <  (d) < Thedayofthe[week/month]onwhichpaymentshouldbemadeis________.)$$<(#<(# ' <'  VIII.  COUNSELFEEREQUIREMENTS f,''  R-(( dd'<@X'  0 <  (a) < Deponentrequestsforcounselfeeanddisbursementsthesumof$________.d<(#<(# dP<0 <  (b) < Deponenthaspaidcounselthesumof$________andhasagreedwithcounselconcerning P feesasfollows:<<(#<(# 0 < ________________________________________________________________________( x<(#<(# 0 < ________________________________________________________________________ d<(#<(# dP  <  0 <  (c) < Thereis[not]aretaineragreementorwrittenagreementrelatingtopaymentoflegalfees.(A P  copyofanysuchagreementmustbeannexed.)< <(#<(# ' <'IX.  ACCOUNTANTANDAPPRAISALFEESREQUIREMENTS (  '<@X'  0 <  (a) < Deponentsrequestforaccountantsfeesanddisbursementsthesumof$________(include  basisforfee,e.g.,hourlyrate,flatrate)<(#<(# d`  0 <  (b) < Deponentrequestsforappraisalfeesanddisbursementsthesumof$________(includebasis  forfee,e.g.,hourlyrate,flatrate)<(#<(# d<0 <  (c) < Deponentrequirestheservicesofanaccountantforthefollowingreasons:<<(#<(# 0 < ________________________________________________________________________(<(#<(# 0 < ________________________________________________________________________<(#<(# dP0 <  (d) < Deponentrequirestheservicesofanappraiserforthefollowingreasons:P<(#<(# 0 < ________________________________________________________________________<<(#<(# 0 < ________________________________________________________________________ (<(#<(# ' <'0   X.  Otherdataconcerningthefinancialcircumstancesofthepartiesthatshouldbebroughttothe # attentionoftheCourtare:$ (#(# 0  ________________________________________________________________________t% !(#(# 0  ________________________________________________________________________`&!"(#(# 0  ________________________________________________________________________L'"#(#(# 0  ________________________________________________________________________8(#$(#(# 0  ________________________________________________________________________$)t$%(#(# 0  ________________________________________________________________________*`%&(#(# Theforegoingstatementsandariderconsistingof________page(s)annexedheretoandmadepart ,$() hereofhavebeencarefullyreadbytheundersigned,whostatesthattheyaretrueandcorrect. -)* .$ p(#X$'pxp(#' p [Petitioner] x [Respondent] t  p [Plaintiff] x [Defendant] ` Sworntobeforemethis________  ` dayof________,_____  L     p s/____________________________    p [AttorneysName]    p [AttorneysAddressandTelphone    p Number]