Statement of Net Worth, Supreme Court of the State of New York Instructions
This form contains 496 fields organized into 135 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| [UCS Rev.1/1/24] | ||
| Amount of Unpaid Liens | Number |
Please enter the amount of any unpaid liens.
|
| Value as of Commencement Date | Number |
Please enter the value as of the date of commencement.
|
| Current Value | Number |
Please enter the current value.
|
| Total Retirement Accounts | Number |
Please enter the total value of retirement accounts.
|
| Affidavit Header | ||
| County | Text |
Please enter the name of the county where the affidavit is being filed.
|
| Affiant's Name | Text |
Please enter the full name of the person making this statement or affidavit.
|
| Statement Date | Date |
Please enter the date as of which this statement of net worth is accurate.
|
| Alimony and Maintenance Payments | ||
| Alimony and Maintenance Payments | Number |
Provide the amount of alimony and maintenance payments made pursuant to a court order or agreement from a prior marriage. Fill only if 'Minor child(ren) of prior marriage' is populated.
Depends on:
Minor Children Count, Custody of Prior Marriage Children
|
| Annuity Payments | ||
| Annuity Payments Amount | Number |
Please enter the amount received from annuity payments.
|
| Automobile Details | ||
| Automobile Year | Text |
Please provide the manufacturing year of the automobile. Fill only if 'Automotive insurance' has a value.
Depends on:
Automotive Insurance Monthly Cost
|
| Automobile Make | Text |
Please provide the make or brand of the automobile. Fill only if 'Automotive insurance' has a value.
Depends on:
Automotive Insurance Monthly Cost
|
| Brokers Margin Accounts | ||
| Broker's Name and Address | Text |
Enter the full name and address of the broker for this margin account.
|
| Original Debt Amount | Number |
Enter the original amount of debt associated with this brokers margin account.
|
| F61 Debt Date | Text | |
| F61 Purpose | Text | |
| F61 Terms | Text | |
| F61 Debt Comm | Text | |
| F61 Debt Current | Text | |
| F61 Broker's Total | Text | |
| Business Valuation | ||
| Net Worth of Business | Number |
Enter the net worth of the business. Fill only if 'Interest in any Business' is 'Yes'
|
| Valuation Date | Date |
Enter the date of the business valuation. Fill only if 'Interest in any Business' is 'Yes'
|
| Car Wash Expense | ||
| Car Wash Expense | Number |
Please provide the monthly expense for car washing. Fill only if 'Automotive insurance' has a value.
Depends on:
Automotive Insurance Monthly Cost
|
| Case Information | ||
| County | Text |
Enter the county where the court case is being filed.
|
| Plaintiff Name | Text |
Provide the full name of the plaintiff in the case.
|
| Index Number | Text |
Enter the index number assigned to this court case.
|
| Defendant Name | Text |
Provide the full name of the defendant in the case.
|
| Date Action Commenced | Date |
Enter the date when the legal action for this case officially began.
|
| Cash Account | ||
| Cash Location | Text |
Enter the location where the cash is held.
|
| Source of Funds | Text |
Enter the source from which the cash funds were obtained.
|
| Amount at Commencement Date | Number |
Enter the amount of cash as of the date of commencement.
|
| Current Cash Amount | Number |
Enter the current amount of cash.
|
| Total Cash | Number |
Enter the total combined cash amount.
|
| Child Support Payments | ||
| Child Support Payments | Number |
Provide the amount of child support payments made for children from a prior marriage or relationship, as per a court order or agreement. Fill only if 'Minor child(ren) of prior marriage' is populated.
Depends on:
Minor Children Count, Custody of Prior Marriage Children
|
| Contingent Interests | ||
| Description | Text |
Provide a description of the contingent interest. Fill only if 'Other Assets or Business Interests' is 'Yes'.
|
| Location | Text |
Specify the location of the contingent interest. Fill only if 'Description' is filled.
Depends on:
Description
|
| Date of Vesting | Date |
Enter the date when the contingent interest vests. Fill only if 'Description' is filled.
Depends on:
Description
|
| Title Owner | Text |
State the name of the title owner for this contingent interest. Fill only if 'Description' is filled.
Depends on:
Description
|
| Date of Acquisition | Date |
Enter the date when the contingent interest was acquired. Fill only if 'Description' is filled.
Depends on:
Description
|
| Original Price or Value | Number |
Provide the original price or value of the contingent interest. Fill only if 'Description' is filled.
Depends on:
Description
|
| Source of Acquisition | Text |
Indicate the source from which the contingent interest was acquired. Fill only if 'Description' is filled.
Depends on:
Description
|
| Method of Valuation | Text |
Describe the method used to value the contingent interest. Fill only if 'Description' is filled.
Depends on:
Description
|
| Value at Commencement Date | Number |
Provide the value of the contingent interest as of the date of commencement. Fill only if 'Description' is filled.
Depends on:
Description
|
| Current Value | Number |
Enter the current value of the contingent interest. Fill only if 'Description' is filled.
Depends on:
Description
|
| Total Contingent Interests | Number |
Enter the total sum of all contingent interests. Fill only if 'Other Assets or Business Interests' is 'Yes'.
|
| Deductions from Gross Income | ||
| Amount Deducted for Retirement or Deferred Savings | Number |
Please provide the total amount deducted from gross income for retirement benefits or tax deferred savings.
|
| Disability Benefits | ||
| Percentage of Lost Wages | Number |
Enter the percentage of your disability benefits that is attributed to lost wages. Fill only if 'Disability Benefits Amount' is filled.
Depends on:
Disability Benefits Amount
|
| Disability Benefits Amount | Number |
Enter the total amount of disability benefits received.
|
| Eighth Rider Section | ||
| Section Number | Text |
Please enter the number of the section this rider is being added to. Fill only if 'Number of rider pages' is greater than 0.
Depends on:
Rider Page Count
|
| Eighth Rider Section Content | Text |
Please provide the additional information for the second section of this Eighth Rider. Fill only if 'Section Number' is not empty.
Depends on:
Section Number
|
| Eleventh Rider Section | ||
| Section Number | Text |
Provide the numerical identifier for this rider section. Fill only if 'Number of rider pages' is greater than 0.
Depends on:
Rider Page Count
|
| Section Details | Text |
Enter the detailed text content for this rider section. Fill only if 'Section Number' is not empty.
Depends on:
Section Number
|
| Employed Household Member Income | ||
| Household Member Name | Text |
Please provide the full name of the employed household member.
|
| Annual Income | Number |
Please provide the annual income of the employed household member.
|
| Fellowships and Stipends | ||
| Fellowships and Stipends Amount | Number |
Please enter the total amount received from fellowships and stipends.
|
| Fifth Rider Section | ||
| Section Number | Text |
Enter the number of the section being added to the Rider. Fill only if 'Number of rider pages' is greater than 0.
Depends on:
Rider Page Count
|
| Section Content | Text |
Provide the detailed content for this section of the Rider. Fill only if 'Section Number' is not empty.
Depends on:
Section Number
|
| First Account Payable Details | ||
| Creditor Name and Address | Text |
Provide the full name and mailing address of the creditor for this account payable.
|
| Debtor Name | Text |
Enter the name of the debtor associated with this account payable.
|
| Original Debt Amount | Number |
Enter the original total amount of the debt.
|
| Debt Incurring Date | Date |
Provide the date on which the debt was originally incurred.
|
| Debt Purpose | Text |
Describe the purpose or reason for incurring this debt.
|
| Periodic Payment Amount | Number |
Enter the amount of the monthly or other periodic payment required for this debt.
|
| Debt Amount at Commencement Date | Number |
Enter the total amount of the debt as of the specified commencement date.
|
| Current Debt Amount | Number |
Enter the current outstanding amount of the debt.
|
| First Asset Transferred | ||
| Property Description | Text |
Provide a detailed description of the asset that was transferred.
|
| Transferee Name and Relationship | Text |
State the name of the person or entity to whom the property was transferred, and describe their relationship to you.
|
| Date of Transfer | Date |
Enter the specific date on which the asset was transferred.
|
| Value | Number |
Provide the monetary value of the asset at the time of transfer.
|
| First Checking Account | ||
| Financial Institution | Text |
Enter the name of the financial institution where this checking account is held.
|
| Account Number | Text |
Enter the account number for this checking account.
|
| Title Holder | Text |
Enter the name of the individual(s) or entity holding the title for this checking account.
|
| Date Opened | Date |
Enter the date on which this checking account was opened.
|
| Source of Funds | Text |
Describe the source from which the funds for this checking account originated.
|
| Balance at Commencement | Number |
Enter the balance of this checking account as of the date of commencement.
|
| Current Balance | Number |
Enter the current balance of this checking account.
|
| First Child of the Marriage | ||
| First Child's Name | Text |
Enter the full name of the first child of the marriage.
|
| First Child's Date of Birth | Date |
Provide the date of birth for the first child of the marriage.
|
| First Credit Card Debt | ||
| Debtor Name | Text |
Please enter the name of the debtor for this credit card debt.
|
| Original Debt Amount | Number |
Please enter the original amount of the debt for this credit card.
|
| Debt Incurring Date | Date |
Please enter the date when this credit card debt was incurred.
|
| Debt Purpose | Text |
Please describe the purpose for which this credit card debt was incurred.
|
| Monthly Payment | Number |
Please enter the monthly or other periodic payment amount for this credit card debt.
|
| Debt Amount at Commencement Date | Number |
Please enter the amount of this credit card debt as of the date of commencement.
|
| Current Debt Amount | Number |
Please enter the current amount of this credit card debt.
|
| First Installment Account Payable | ||
| Creditor Name and Address | Text |
Enter the full name and address of the creditor for this installment account.
|
| Debtor Name | Text |
Enter the name of the debtor for this installment account.
|
| Original Debt Amount | Number |
Enter the original amount of the debt for this installment account.
|
| Debt Incurring Date | Date |
Enter the date when this debt was incurred.
|
| Debt Purpose | Text |
Enter the purpose for which this debt was incurred.
|
| First Investment Account Details | ||
| Description | Text |
Provide a description of the investment account, security, stock option, commodity, or broker margin account.
|
| Title Holder | Text |
Enter the name of the person or entity holding the title for this investment account. Fill only if 'Description' is not empty.
Depends on:
Description
|
| Location | Text |
Specify the physical location or jurisdiction where this investment account is held. Fill only if 'Description' is not empty.
Depends on:
Description
|
| Date of Acquisition | Date |
Enter the date when this investment account was acquired. Fill only if 'Description' is not empty.
Depends on:
Description
|
| Source of Funds | Text |
Indicate the origin of the funds used for this investment account. Fill only if 'Description' is not empty.
Depends on:
Description
|
| Value as of Commencement Date | Number |
Provide the value of the investment account at the time of its commencement. Fill only if 'Description' is not empty.
Depends on:
Description
|
| Current Value | Number |
Enter the current market value of the investment account. Fill only if 'Description' is not empty.
Depends on:
Description
|
| First Life Insurance Policy Details | ||
| Insurer's Name and Address (Policy 1) | Text |
Enter the name and address of the insurer for the first life insurance policy. Fill only if 'Interest in any Business' is 'Yes'
|
| Name of Insured (Policy 1) | Text |
Enter the full name of the individual insured under the first life insurance policy. Fill only if 'Interest in any Business' is 'Yes'
|
| Policy Number (Policy 1) | Text |
Enter the policy number for the first life insurance policy. Fill only if 'Interest in any Business' is 'Yes'
|
| Face Amount of Policy (Policy 1) | Number |
Enter the face amount or coverage amount of the first life insurance policy. Fill only if 'Interest in any Business' is 'Yes'
|
| Policy Owner (Policy 1) | Text |
Enter the full name of the owner of the first life insurance policy. Fill only if 'Interest in any Business' is 'Yes'
|
| Date of Acquisition (Policy 1) | Date |
Enter the date when the first life insurance policy was acquired. Fill only if 'Interest in any Business' is 'Yes'
|
| Source of Funds (Policy 1) | Text |
Enter the source of funds used to acquire the first life insurance policy. Fill only if 'Interest in any Business' is 'Yes'
|
| Cash Surrender Value at Commencement (Policy 1) | Number |
Enter the cash surrender value of the first life insurance policy as of its commencement date. Fill only if 'Interest in any Business' is 'Yes'
|
| Current Cash Surrender Value (Policy 1) | Number |
Enter the current cash surrender value of the first life insurance policy. Fill only if 'Interest in any Business' is 'Yes'
|
| First Mortgage Payable | ||
| Mortgagee Name and Address | Text |
Enter the full name and address of the mortgagee for this mortgage. Fill only if 'Real Estate' is filled.
Depends on:
Description, Title Owner, Date of Acquisition, Original Price
|
| Property Mortgaged Address | Text |
Enter the full address of the property that is mortgaged. Fill only if 'Mortgagee Name and Address' is filled.
Depends on:
Mortgagee Name and Address
|
| Mortgagor(s) Name | Text |
Enter the full name(s) of the mortgagor(s) for this mortgage. Fill only if 'Mortgagee Name and Address' is filled.
Depends on:
Mortgagee Name and Address
|
| Original Debt Amount | Number |
Enter the original amount of the debt incurred for this mortgage. Fill only if 'Mortgagee Name and Address' is filled.
Depends on:
Mortgagee Name and Address
|
| Debt Incurrence Date | Date |
Enter the date on which this debt was incurred. Fill only if 'Mortgagee Name and Address' is filled.
Depends on:
Mortgagee Name and Address
|
| Periodic Payment Amount | Number |
Enter the amount of the monthly or other periodic payment for this mortgage. Fill only if 'Mortgagee Name and Address' is filled.
Depends on:
Mortgagee Name and Address
|
| Maturity Date | Date |
Enter the date when the mortgage debt is due to be fully repaid. Fill only if 'Mortgagee Name and Address' is filled.
Depends on:
Mortgagee Name and Address
|
| Debt Amount at Commencement Date | Number |
Enter the total amount of debt as of the specified commencement date. Fill only if 'Mortgagee Name and Address' is filled.
Depends on:
Mortgagee Name and Address
|
| Current Debt Amount | Number |
Enter the current outstanding amount of the debt. Fill only if 'Mortgagee Name and Address' is filled.
Depends on:
Mortgagee Name and Address
|
| First Other Liability | ||
| Description | Text |
Please enter a description of the other liability.
|
| Creditor Name and Address | Text |
Please provide the name and address of the creditor for this liability.
|
| Debtor | Text |
Please enter the name of the debtor for this liability.
|
| Original Amount of Debt | Number |
Please provide the original amount of the debt.
|
| Date Incurred | Date |
Please enter the date when this liability was incurred.
|
| Purpose | Text |
Please describe the purpose of this liability.
|
| Monthly or Other Periodic Payment | Number |
Please provide the monthly or other periodic payment amount for this liability.
|
| Amount of Debt at Commencement | Number |
Please provide the total amount of debt as of the date of commencement.
|
| Amount of Current Debt | Number |
Please provide the current outstanding amount of the debt.
|
| First Other Monthly Expense | ||
| Other Monthly Expense Description | Text |
Please provide a description for the first other monthly expense.
|
| Other Monthly Expense Amount | Number |
Enter the monthly amount for the first other expense. Fill only if 'Other Monthly Expense Description' is filled.
Depends on:
Other Monthly Expense Description
|
| First Real Estate Item | ||
| Source of Funds to Acquire | Text |
Provide the source of funds used to acquire the real estate item.
|
| Unpaid Mortgage/Lien Amount | Number |
Enter the current outstanding amount of any mortgage or lien on the real estate item.
|
| Estimated Current Fair Market Value | Number |
Provide the estimated current fair market value of the real estate item.
|
| First Retirement Account | ||
| Description | Text |
Provide a description of the retirement account, such as its type or specific characteristics.
|
| Location of Assets | Text |
Enter the physical or institutional location where the assets of the retirement account are held.
|
| Title Owner | Text |
State the name of the individual or entity who legally owns the retirement account.
|
| Date of Acquisition | Date |
Provide the date when the retirement account was established or acquired.
|
| Source of Funds | Text |
Describe the origin or source of the funds used to establish or contribute to this retirement account.
|
| Amount of Unpaid Liens | Number |
Enter the total outstanding amount of any liens against the retirement account.
|
| Value as of Commencement Date | Number |
Provide the financial value of the retirement account on the specified date of commencement.
|
| Current Value | Number |
Enter the most recent estimated financial value of the retirement account.
|
| First Rider Section | ||
| Rider Section Number | Text |
Please specify the section number to which this rider is being added. Fill only if 'Number of rider pages' is greater than 0.
Depends on:
Rider Page Count
|
| Rider Content | Text |
Please provide the full text content for this rider section. Fill only if 'Rider Section Number' is not empty.
Depends on:
Rider Section Number
|
| First Savings Account | ||
| Financial Institution | Text |
Provide the name of the financial institution where the savings account is held.
|
| Account Number | Text |
Enter the account number for this savings account.
|
| Title Holder | Text |
Provide the name of the title holder(s) for this savings account.
|
| Type of Account | Text |
Specify the type of savings account, such as individual, joint, or trust.
|
| Date Opened | Date |
Enter the date when this savings account was opened.
|
| Source of Funds | Text |
Indicate the origin or source of the funds deposited into this account.
|
| Balance as of Commencement Date | Number |
Enter the balance of the savings account on the date of commencement.
|
| Current Balance | Number |
Enter the current balance of the savings account.
|
| First Vehicle Details | ||
| Vehicle Description | Text |
Please provide a detailed description of the first vehicle.
|
| Title Owner | Text |
Please enter the name of the legal owner of the first vehicle.
|
| Date of Acquisition | Date |
Please enter the date the first vehicle was acquired.
|
| Original Price | Number |
Please enter the original purchase price of the first vehicle.
|
| Source of Funds to Acquire | Text |
Please specify the source of funds used to acquire the first vehicle.
|
| Amount of Unpaid Lien | Number |
Please enter the outstanding amount of any lien on the first vehicle.
|
| Current Fair Market Value | Number |
Please enter the current fair market value of the first vehicle.
|
| Value at Commencement Date | Number |
Please enter the value of the first vehicle as of the commencement date.
|
| Food Stamps | ||
| Food Stamps Benefit Amount | Number |
Provide the total amount received from food stamps.
|
| Food: Monthly | ||
| Food Groceries | Text | |
| Food Dining | Text | |
| Food Other | Text | |
| TOTAL Food | Text | |
| Fourth Rider Section | ||
| Section Number | Text |
Please provide the number of the section you are adding to. Fill only if 'Number of rider pages' is greater than 0.
Depends on:
Rider Page Count
|
| Rider Section Content | Text |
Provide the additional content or details for the specified rider section. Fill only if 'Section Number' is not empty.
Depends on:
Section Number
|
| Gas and Oil Expense | ||
| Gas and Oil | Number |
Enter the monthly amount spent on gas and oil. Fill only if 'Automotive insurance' has a value.
Depends on:
Automotive Insurance Monthly Cost
|
| General | ||
| Personal | Checkbox |
Check this box if the automobile listed is for personal use. Fill only if 'Automotive insurance' has a value.
Depends on:
Automotive Insurance Monthly Cost
|
| Business | Checkbox |
Check this box if the automobile listed is for business use. Fill only if 'Automotive insurance' has a value.
Depends on:
Automotive Insurance Monthly Cost
|
| Gross Income | ||
| Gross Total Income | Number |
Provide the gross (total) income that was reported in your most recent Federal income tax return.
|
| Home Equity and Other Lines of Credit Details | ||
| Mortgagee Name and Address | Text |
Please provide the full name and address of the mortgagee for this line of credit.
|
| Property Mortgaged Address | Text |
Please provide the full address of the property that is mortgaged for this line of credit.
|
| Mortgagor(s) | Text |
Please provide the name(s) of the mortgagor(s) for this line of credit.
|
| Original Debt Amount | Number |
Please provide the original amount of the debt incurred for this line of credit.
|
| Debt Incurring Date | Date |
Please provide the date on which this debt was incurred.
|
| Monthly or Periodic Payment Amount | Number |
Please provide the amount of the monthly or other periodic payment for this line of credit.
|
| Maturity Date | Date |
Please provide the maturity date of this line of credit.
|
| Debt Amount at Commencement Date | Number |
Please provide the amount of debt as of the date the line of credit commenced.
|
| Current Debt Amount | Number |
Please provide the current outstanding amount of debt for this line of credit.
|
| Household Help Expenses | ||
| Domestic Household Help Monthly Expenses | Number |
Enter the monthly expenses for domestic household help, such as a housekeeper.
|
| Nanny/Au Pair/Child Care Monthly Expenses | Number |
Enter the monthly expenses for nanny, au pair, or child care services.
|
| Babysitter Monthly Expenses | Number |
Enter the monthly expenses for babysitter services.
|
| Other Household Help Monthly Expenses | Number |
Enter any other monthly expenses for household help not listed above.
|
| Total Household Help Monthly Expenses | Number |
Enter the total monthly expenses for all household help services.
|
| Household Maintenance Expenses | ||
| Repairs/Maintenance Monthly | Number |
Enter the monthly amount spent on repairs and maintenance for the household.
|
| Gardening/Landscaping Monthly | Number |
Enter the monthly amount spent on gardening and landscaping services.
|
| Sanitation/Carting Monthly | Number |
Enter the monthly amount spent on sanitation and carting services.
|
| Snow Removal Monthly | Number |
Enter the monthly amount spent on snow removal services.
|
| Extermination Monthly | Number |
Enter the monthly amount spent on extermination services.
|
| Other Household Maintenance Monthly | Number |
Enter the monthly amount for any other household maintenance expenses not listed above.
|
| Total Household Maintenance Monthly | Number |
Enter the total monthly amount for all household maintenance expenses.
|
| Installment Account Details | ||
| Monthly or Periodic Payment | Number |
Enter the monthly or other periodic payment amount for the installment account.
|
| Debt Amount at Commencement | Number |
Enter the total amount of debt as of the date the installment account commenced.
|
| Current Debt Amount | Number |
Enter the current outstanding amount of debt for the installment account.
|
| Insurance Expenses | ||
| Worker's Compensation Expense | Number |
Please enter the total amount paid for worker's compensation insurance.
|
| Long Term Care Insurance Expense | Number |
Please enter the total amount paid for long term care insurance.
|
| Other Insurance Expense | Number |
Please enter the total amount paid for any other unspecified insurance.
|
| Total Insurance Expense | Number |
Please enter the total sum of all insurance expenses.
|
| Interest in Business | ||
| Name and Address of Business | Text |
Please enter the full name and address of the business.
|
| Type of Business | Text |
Please enter the legal structure of the business, such as corporate, partnership, or sole proprietorship.
|
| Percentage of Interest | Text |
Please enter your percentage of ownership or interest in the business.
|
| Date of Acquisition | Date |
Please enter the date when you acquired your interest in the business.
|
| Original Price or Value | Number |
Please enter the original price or value at which your interest in the business was acquired.
|
| Investment Account Totals | ||
| Total Investment Account Count | Text |
Enter the total number of investment accounts, securities, stock options, commodities, and broker margin accounts.
|
| Total Value of Securities | Number |
Enter the total monetary value of all securities.
|
| Investment Income | ||
| Investment Income | Number |
Provide the total amount of investment income, including interest and dividend income, reduced by any sums expended in connection with such investment.
|
| Jewelry/Art Item 7.1 | ||
| Item Description | Text |
Provide a detailed description of the jewelry, art, or precious metal item. Fill only if 'E71 Value Current' is valued at more than $500.
Depends on:
E71 Value Current
|
| Title Owner | Text |
Enter the name of the individual or entity that legally owns the item. Fill only if 'E71 Value Current' is valued at more than $500.
Depends on:
E71 Value Current
|
| E71 Location | Text |
Depends on:
E71 Value Current
|
| E71 Original Price | Text |
Depends on:
E71 Value Current
|
| E71 Source | Text |
Depends on:
E71 Value Current
|
| E71 Unpaid Lien | Text |
Depends on:
E71 Value Current
|
| E71 Value Date | Text |
Depends on:
E71 Value Current
|
| E71 Value Current | Text | |
| Jewelry/Art Item 7.2 | ||
| Description | Text |
Enter a detailed description of the jewelry or art item. Fill only if 'Estimated Current Value' is valued at more than $500.
Depends on:
Estimated Current Value
|
| Title Owner | Text |
Provide the name of the legal title owner of the item. Fill only if 'Estimated Current Value' is valued at more than $500.
Depends on:
Estimated Current Value
|
| Location | Text |
Specify the current physical location of the item. Fill only if 'Estimated Current Value' is valued at more than $500.
Depends on:
Estimated Current Value
|
| Original Price or Value | Number |
Enter the original purchase price or estimated value of the item. Fill only if 'Estimated Current Value' is valued at more than $500.
Depends on:
Estimated Current Value
|
| Source of Funds | Text |
Indicate the source of funds used to acquire the item. Fill only if 'Estimated Current Value' is valued at more than $500.
Depends on:
Estimated Current Value
|
| Lien Unpaid Amount | Number |
State the remaining unpaid amount of any lien on the item. Fill only if 'Estimated Current Value' is valued at more than $500.
Depends on:
Estimated Current Value
|
| Value as of Commencement Date | Number |
Provide the value of the item as of the commencement date. Fill only if 'Estimated Current Value' is valued at more than $500.
Depends on:
Estimated Current Value
|
| Estimated Current Value | Number |
Enter the estimated current market value of the item.
|
| Lease or Loan Payments | ||
| Lease Term | Text |
Please provide the term of the lease or loan in months. Fill only if 'Monthly Payment Amount' is filled and represents a lease payment.
Depends on:
Monthly Payment Amount
|
| Monthly Payment Amount | Number |
Please enter the monthly amount for lease or loan payments. Fill only if 'Automotive insurance' has a value.
Depends on:
Automotive Insurance Monthly Cost
|
| Legal & Expert Fees | ||
| Legal and Expert Fees Paid | Text |
Provide details about all legal and expert fees paid in connection with your marital dissolution, including the name of each professional, amounts, dates of payment, and the source of funds.
|
| Loan Details | ||
| Debtor's Name and Address | Text |
Please provide the full name and address of the debtor. Fill only if 'Other Assets or Business Interests' exists
|
| Original Amount of Loan or Debt | Number |
Please enter the initial amount of the loan or debt. Fill only if 'Other Assets or Business Interests' exists
|
| Source of Funds for Loan/Debt | Text |
Please specify the source from which the loan was made or the origin of the debt. Fill only if 'Other Assets or Business Interests' exists
|
| Date Payment(s) Due | Date |
Please enter the date(s) when the payment(s) are due. Fill only if 'Other Assets or Business Interests' exists
|
| Amount Due as of Commencement Date | Number |
Please enter the amount due as of the specified date of commencement. Fill only if 'Other Assets or Business Interests' exists
|
| Current Amount Due | Number |
Please enter the current total amount that is due. Fill only if 'Other Assets or Business Interests' exists
|
| Loan Payments | ||
| Loan Payments Amount | Number |
Provide the total amount of loan payments.
|
| Loans on Life Insurance Policies | ||
| Insurer Name and Address | Text |
Please provide the full name and address of the insurance company that issued the policy. Fill only if 'Cash Surrender Value of Life Insurance' is reported.
Depends on:
Total Cash Surrender Value
|
| Loan Amount | Number |
Enter the total monetary value of the loan. Fill only if 'Cash Surrender Value of Life Insurance' is reported.
Depends on:
Total Cash Surrender Value
|
| Date Incurred | Date |
Provide the date when the loan was incurred. Fill only if 'Cash Surrender Value of Life Insurance' is reported.
Depends on:
Total Cash Surrender Value
|
| Loan Purpose | Text |
Describe the reason or purpose for which the loan was taken out. Fill only if 'Cash Surrender Value of Life Insurance' is reported.
Depends on:
Total Cash Surrender Value
|
| Borrower Name | Text |
Enter the full name of the borrower. Fill only if 'Cash Surrender Value of Life Insurance' is reported.
Depends on:
Total Cash Surrender Value
|
| Periodic Payment Amount | Number |
Provide the amount of the monthly or other regular periodic payment. Fill only if 'Cash Surrender Value of Life Insurance' is reported.
Depends on:
Total Cash Surrender Value
|
| Debt Amount at Commencement | Number |
Enter the total amount of debt as of the specified commencement date. Fill only if 'Cash Surrender Value of Life Insurance' is reported.
Depends on:
Total Cash Surrender Value
|
| Current Debt Amount | Number |
Provide the current outstanding amount of the debt. Fill only if 'Cash Surrender Value of Life Insurance' is reported.
Depends on:
Total Cash Surrender Value
|
| Total Loans on Life Insurance | Number |
Enter the calculated total sum of all loans on life insurance policies. Fill only if 'Cash Surrender Value of Life Insurance' is reported.
Depends on:
Total Cash Surrender Value
|
| Maintenance and/or Child Support | ||
| Amount Received | Number |
Provide the total amount of maintenance and/or child support you are receiving pursuant to a court order or agreement.
|
| Marriage Date | ||
| Marriage Date | Date |
Please enter the date of marriage.
|
| Monthly Clothing Expenses | ||
| Monthly Clothing Expense - Yourself | Number |
Enter the total monthly clothing expenses for yourself.
|
| Monthly Clothing Expense - Child(ren) | Number |
Enter the total monthly clothing expenses for your child or children. Fill only if 'Child(ren) of the marriage' is filled.
Depends on:
First Child's Name, First Child's Date of Birth, Second Child Name, Second Child Date of Birth
|
| Monthly Clothing Expense - Dry Cleaning | Number |
Enter the total monthly expenses for dry cleaning.
|
| Monthly Clothing Expense - Other | Number |
Enter any other monthly clothing-related expenses not specified elsewhere.
|
| Total Monthly Clothing Expenses | Number |
Enter the calculated total monthly clothing expenses from all categories.
|
| Monthly Education Costs | ||
| Nursery and Pre-school Costs | Number |
Enter the monthly cost for nursery and pre-school education. Fill only if 'Child(ren) of the marriage' is filled
Depends on:
First Child's Name, First Child's Date of Birth, Second Child Name, Second Child Date of Birth
|
| Primary and Secondary School Costs | Number |
Enter the monthly cost for primary and secondary school education. Fill only if 'Child(ren) of the marriage' is filled
Depends on:
First Child's Name, First Child's Date of Birth, Second Child Name, Second Child Date of Birth
|
| College Costs | Number |
Enter the monthly cost for college education. Fill only if 'Child(ren) of the marriage' is filled
Depends on:
First Child's Name, First Child's Date of Birth, Second Child Name, Second Child Date of Birth
|
| Post-Graduate Costs | Number |
Enter the monthly cost for post-graduate education. Fill only if 'Child(ren) of the marriage' is filled
Depends on:
First Child's Name, First Child's Date of Birth, Second Child Name, Second Child Date of Birth
|
| Religious Instruction Costs | Number |
Enter the monthly cost for religious instruction. Fill only if 'Child(ren) of the marriage' is filled
Depends on:
First Child's Name, First Child's Date of Birth, Second Child Name, Second Child Date of Birth
|
| School Transportation Costs | Number |
Enter the monthly cost for school transportation. Fill only if 'Child(ren) of the marriage' is filled
Depends on:
First Child's Name, First Child's Date of Birth, Second Child Name, Second Child Date of Birth
|
| School Supplies and Books Costs | Number |
Enter the monthly cost for school supplies and books. Fill only if 'Child(ren) of the marriage' is filled
Depends on:
First Child's Name, First Child's Date of Birth, Second Child Name, Second Child Date of Birth
|
| School Lunches Costs | Number |
Enter the monthly cost for school lunches. Fill only if 'Child(ren) of the marriage' is filled
Depends on:
First Child's Name, First Child's Date of Birth, Second Child Name, Second Child Date of Birth
|
| Tutoring Costs | Number |
Enter the monthly cost for tutoring services. Fill only if 'Child(ren) of the marriage' is filled
Depends on:
First Child's Name, First Child's Date of Birth, Second Child Name, Second Child Date of Birth
|
| School Events Costs | Number |
Enter the monthly cost for school events. Fill only if 'Child(ren) of the marriage' is filled
Depends on:
First Child's Name, First Child's Date of Birth, Second Child Name, Second Child Date of Birth
|
| Child's Extra-Curricular/Enrichment Costs | Number |
Enter the monthly cost for child(ren)'s extra-curricular and educational enrichment activities, such as dance, music, or sports. Fill only if 'Child(ren) of the marriage' is filled
Depends on:
First Child's Name, First Child's Date of Birth, Second Child Name, Second Child Date of Birth
|
| Other Education Costs | Number |
Enter any other monthly education costs not listed above. Fill only if 'Child(ren) of the marriage' is filled
Depends on:
First Child's Name, First Child's Date of Birth, Second Child Name, Second Child Date of Birth
|
| Total Monthly Education Costs | Number |
Enter the total monthly cost for all education-related expenses. Fill only if 'Nursery and Pre-school Costs', 'Primary and Secondary School Costs', 'College Costs', 'Post-Graduate Costs', 'Religious Instruction Costs', 'School Transportation Costs', 'School Supplies and Books Costs', 'School Lunches Costs', 'Tutoring Costs', 'School Events Costs', 'Child's Extra-Curricular/Enrichment Costs', 'Other Education Costs' is the sum of fields 1-12.
Depends on:
Nursery and Pre-school Costs, Primary and Secondary School Costs, College Costs, Post-Graduate Costs, Religious Instruction Costs, School Transportation Costs, School Supplies and Books Costs, School Lunches Costs, Tutoring Costs, School Events Costs, Child's Extra-Curricular/Enrichment Costs, Other Education Costs
|
| Monthly Housing Expenses | ||
| Mortgage/Co-op Loan | Number |
Enter the monthly amount for your mortgage or co-op loan.
|
| Home Equity Line of Credit/Second Mortgage | Number |
Enter the monthly payment amount for your home equity line of credit or second mortgage.
|
| Real Estate Taxes | Number |
Enter the monthly amount for real estate taxes, if not already included in your mortgage payment. Fill only if 'Mortgage/Co-op Loan' is not included in mortgage payment.
Depends on:
Mortgage/Co-op Loan
|
| Homeowners/Renter's Insurance | Number |
Enter the monthly amount for your homeowner's or renter's insurance.
|
| Homeowner's Association/Maintenance/Condo Charges | Number |
Enter the monthly amount for homeowner's association fees, maintenance charges, or condominium charges.
|
| Rent | Number |
Enter the monthly amount you pay for rent.
|
| Other Housing Expenses | Number |
Enter the total monthly amount for any other housing-related expenses not listed above.
|
| Total Monthly Housing Expenses | Number |
Enter the total monthly sum of all housing expenses listed above.
|
| Monthly Income Taxes | ||
| Federal Income Tax | Number |
Enter the monthly amount paid for federal income tax.
|
| State Income Tax | Number |
Enter the monthly amount paid for state income tax.
|
| City Income Tax | Number |
Enter the monthly amount paid for city income tax.
|
| Social Security and Medicare | Number |
Enter the monthly amount paid for Social Security and Medicare.
|
| Number of Dependents | Number |
Enter the number of dependents claimed in the prior tax year.
|
| Prior Tax Year Refund | Number |
Enter the amount of any income tax refund received for the prior tax year.
|
| Total Monthly Income Taxes | Number |
Enter the total monthly amount for income taxes, including federal, state, city, and Social Security/Medicare.
|
| Monthly Insurance | ||
| Life Insurance Monthly Cost | Number |
Enter the monthly cost for life insurance.
|
| Fire, Theft, Liability, and Personal Articles Policy Monthly Cost | Number |
Enter the monthly cost for fire, theft, liability, and personal articles insurance policy. Fill only if 'Mortgage Payment' does not include this cost
Depends on:
Mortgage/Co-op Loan
|
| Automotive Insurance Monthly Cost | Number |
Enter the monthly cost for automotive insurance.
|
| Umbrella Policy Monthly Cost | Number |
Enter the monthly cost for the umbrella insurance policy.
|
| Medical Plan Monthly Cost | Number |
Enter the total monthly cost for medical plans.
|
| Medical Plan for Self | Text |
Enter the monthly cost for your medical plan, including the name of the carrier and name of the insured. Fill only if 'Medical Plan Monthly Cost' has a value.
Depends on:
Medical Plan Monthly Cost
|
| Medical Plan for Children | Text |
Enter the monthly cost for the medical plan covering children, including the name of the carrier and name of the insured. Fill only if 'Medical Plan Monthly Cost' has a value.
Depends on:
Medical Plan Monthly Cost
|
| Dental Plan Monthly Cost | Number |
Enter the monthly cost for the dental plan.
|
| Optical Plan Monthly Cost | Number |
Enter the monthly cost for the optical plan.
|
| Disability Insurance Monthly Cost | Number |
Enter the monthly cost for disability insurance.
|
| Monthly Miscellaneous Expenses | ||
| Beauty Parlor/Barber/Spa Monthly Expense | Number |
Enter the total monthly expense for beauty parlor, barber, or spa services.
|
| Toiletries/Non-Prescription Drugs Monthly Expense | Number |
Enter the total monthly expense for toiletries and non-prescription drugs.
|
| Books, Magazines, Newspapers Monthly Expense | Number |
Enter the total monthly expense for books, magazines, and newspapers.
|
| Gifts to Others Monthly Expense | Number |
Enter the total monthly expense for gifts given to others.
|
| Charitable Contributions Monthly Expense | Number |
Enter the total monthly expense for charitable contributions.
|
| Religious Organizations Dues Monthly Expense | Number |
Enter the total monthly expense for religious organization dues.
|
| Union and Organization Dues Monthly Expense | Number |
Enter the total monthly expense for union and other organization dues.
|
| Commutation Expenses Monthly | Number |
Enter the total monthly commutation expenses.
|
| Veterinarian/Pet Expenses Monthly | Number |
Enter the total monthly veterinarian and other pet-related expenses.
|
| Monthly Utilities Expenses | ||
| Monthly Fuel Oil/Gas Expense | Number |
Please provide the monthly expense for fuel oil or gas.
|
| Monthly Electric Expense | Number |
Please provide the monthly expense for electricity.
|
| Monthly Landline Telephone Expense | Number |
Please provide the monthly expense for landline telephone service.
|
| Monthly Mobile Phone Expense | Number |
Please provide the monthly expense for mobile phone service.
|
| Monthly Cable/Satellite TV Expense | Number |
Please provide the monthly expense for cable or satellite TV service.
|
| Monthly Internet Expense | Number |
Please provide the monthly expense for internet service.
|
| Monthly Alarm Expense | Number |
Please provide the monthly expense for alarm system service.
|
| Monthly Water Expense | Number |
Please provide the monthly expense for water.
|
| Monthly Other Utility Expense | Number |
Please provide the monthly expense for any other utility not listed.
|
| Total Monthly Utilities | Number |
Please provide the total monthly expenses for all utilities listed above.
|
| Ninth Rider Section | ||
| Ninth Rider Sub-section Identifier | Text |
Please enter the identifying number or code for this specific sub-section of the Ninth Rider. Fill only if 'Number of rider pages' is greater than 0.
Depends on:
Rider Page Count
|
| Ninth Rider Section Content | Text |
Please provide the detailed content for this section of the Ninth Rider. Fill only if 'Ninth Rider Sub-section Identifier' is not empty.
Depends on:
Ninth Rider Sub-section Identifier
|
| Notes Payable | ||
| Name and Address of Noteholder | Text |
Please provide the full name and address of the noteholder.
|
| Debtor | Text |
Please enter the name of the debtor.
|
| Amount of Original Debt | Number |
Please enter the original amount of the debt.
|
| Date of Incurring Debt | Date |
Please provide the date when the debt was incurred.
|
| Purpose | Text |
Please describe the purpose of the debt.
|
| Monthly or Other Periodic Payment | Number |
Please enter the amount of the monthly or other periodic payment.
|
| Amount of Debt as of Commencement Date | Number |
Please enter the total amount of debt as of the date of commencement.
|
| Amount of Current Debt | Number |
Please enter the current total amount of the debt.
|
| Total Notes Payable | Number |
Please enter the total sum of all notes payable.
|
| Other Assets | ||
| Other Asset Description | Text |
Provide a detailed description of the other asset. Fill only if 'Other Assets or Business Interests' is 'Yes'.
|
| Title Owner | Text |
Enter the name of the individual or entity that legally owns this asset. Fill only if 'Other Asset Description' is filled.
Depends on:
Other Asset Description
|
| Asset Location | Text |
Specify the physical location of the other asset. Fill only if 'Other Asset Description' is filled.
Depends on:
Other Asset Description
|
| Original Price or Value | Number |
Enter the original price or value of the asset. Fill only if 'Other Asset Description' is filled.
Depends on:
Other Asset Description
|
| Source of Acquisition Funds | Text |
Indicate the source of funds used to acquire this asset. Fill only if 'Other Asset Description' is filled.
Depends on:
Other Asset Description
|
| Unpaid Lien Amount | Number |
Enter the outstanding amount of any lien on this asset. Fill only if 'Other Asset Description' is filled.
Depends on:
Other Asset Description
|
| Value at Commencement Date | Number |
Enter the value of the asset as of the commencement date. Fill only if 'Other Asset Description' is filled.
Depends on:
Other Asset Description
|
| Current Value | Number |
Enter the current market value of the asset. Fill only if 'Other Asset Description' is filled.
Depends on:
Other Asset Description
|
| Total Other Assets | Number |
Enter the calculated total value of all other assets. Fill only if 'Other Assets or Business Interests' is 'Yes'.
|
| Other Automobile Expense | ||
| Other Automobile Expense | Number |
Enter the monthly amount for other automobile expenses not specifically listed above. Fill only if 'Automotive insurance' has a value.
Depends on:
Automotive Insurance Monthly Cost
|
| Other Data Concerning Financial Circumstances | ||
| Other Financial Data | Text |
Provide any other relevant financial circumstances of the parties that should be brought to the attention of the court.
|
| Other Income | ||
| Other Income Amount | Number |
Enter the amount of any other income not previously listed.
|
| Other Relevant Information | ||
| Other Relevant Information | Text |
Provide any other relevant information for this section. Fill only if 'Interest in any Business' is 'Yes'
|
| Parking and Tolls Expense | ||
| Monthly Parking and Tolls | Number |
Enter the total monthly expense incurred for parking and tolls. Fill only if 'Automotive insurance' has a value.
Depends on:
Automotive Insurance Monthly Cost
|
| Party Addresses | ||
| Plaintiff's Address | Text |
Please enter the plaintiff's current residential or mailing address.
|
| Defendant's Address | Text |
Please enter the defendant's current residential or mailing address.
|
| Party Birth Dates | ||
| Plaintiff's Date of Birth | Date |
Enter the plaintiff's date of birth.
|
| Defendant's Date of Birth | Date |
Enter the defendant's date of birth.
|
| Party Employment Information | ||
| Plaintiff's Occupation/Employer | Text |
Provide the plaintiff's current occupation and employer.
|
| Defendant's Occupation/Employer | Text |
Provide the defendant's current occupation and employer.
|
| Pensions and Retirement Benefits | ||
| Pensions and Retirement Benefits | Number |
Please provide the total amount received from pensions and retirement benefits.
|
| Prior Marriage Children Information | ||
| Minor Children Count | Number |
Enter the total number of minor children from a prior marriage.
|
| Custody of Prior Marriage Children | Text |
Provide details regarding the custody arrangements for children from a prior marriage.
|
| Public Assistance | ||
| Public Assistance Amount | Number |
Provide the total amount received from public assistance.
|
| Real Estate Information | ||
| Description | Text |
Enter a brief description of the real estate.
|
| Title Owner | Text |
Enter the name of the legal owner(s) of the real estate.
|
| Date of Acquisition | Date |
Enter the date the real estate was acquired.
|
| Original Price | Number |
Enter the original purchase price of the real estate.
|
| Recreational Expenses | ||
| Music Expenses | Number |
Enter the total monthly expenses for music, including digital or physical media.
|
| Recreation Clubs and Memberships Expenses | Number |
Enter the total monthly expenses for recreation clubs and memberships.
|
| Personal Activities Expenses | Number |
Enter the total monthly expenses for recreational activities for yourself.
|
| Health Club Expenses | Number |
Enter the total monthly expenses for health club memberships or services.
|
| Summer Camp Expenses | Number |
Enter the total monthly expenses for summer camp. Fill only if 'Names and dates of birth of Child(ren) of the marriage' has entries
Depends on:
First Child's Name, First Child's Date of Birth, Second Child Name, Second Child Date of Birth
|
| Children's Birthday Party Costs | Number |
Enter the total monthly costs for your child(ren)'s birthday parties. Fill only if 'Names and dates of birth of Child(ren) of the marriage' has entries
Depends on:
First Child's Name, First Child's Date of Birth, Second Child Name, Second Child Date of Birth
|
| Other Recreational Expenses | Number |
Enter any other miscellaneous monthly recreational expenses not explicitly listed.
|
| Total Recreational Expenses | Number |
Enter the calculated total monthly recreational expenses.
|
| Recreational: Monthly | ||
| Vacations | Number |
Please provide the monthly cost for vacations.
|
| Movies, Theatre, Ballet, Etc. | Number |
Please provide the monthly cost for movies, theatre, ballet, and similar entertainment.
|
| Repairs Expense | ||
| Monthly Repairs Expense | Number |
Enter the monthly amount spent on automobile repairs. Fill only if 'Automotive insurance' has a value.
Depends on:
Automotive Insurance Monthly Cost
|
| Rider Page Count | ||
| Rider Page Count | Number |
Enter the total number of pages consisting of the annexed rider.
|
| Safe Deposit Box Rental Fee | ||
| Rental Fee Amount | Number |
Enter the amount of the safe deposit box rental fee.
|
| Second Account Payable Details | ||
| Creditor Name and Address | Text |
Provide the full name and address of the creditor.
|
| Debtor Name | Text |
Provide the name of the debtor.
|
| Original Debt Amount | Number |
Enter the original amount of the debt.
|
| Debt Incurring Date | Date |
Provide the date when the debt was incurred.
|
| Debt Purpose | Text |
Explain the purpose for which the debt was incurred.
|
| Periodic Payment Amount | Number |
Enter the amount of any monthly or other periodic payment for this debt.
|
| Debt Amount at Commencement Date | Number |
Provide the total amount of debt as of the date of commencement.
|
| Current Debt Amount | Number |
Enter the current outstanding amount of the debt.
|
| Second Checking Account | ||
| Financial Institution | Text |
Enter the name of the financial institution where the second checking account is held.
|
| Account Number | Text |
Provide the account number for the second checking account.
|
| Title Holder | Text |
Enter the full name of the primary title holder for the second checking account.
|
| Date Opened | Date |
Enter the date when the second checking account was opened.
|
| Source of Funds | Text |
Specify the source of funds for the second checking account.
|
| Balance at Commencement | Number |
Provide the balance of the second checking account as of the date of commencement.
|
| Current Balance | Number |
Enter the current balance of the second checking account.
|
| Second Child of the Marriage | ||
| Second Child Name | Text |
Enter the full name of the second child from the marriage.
|
| Second Child Date of Birth | Date |
Enter the date of birth for the second child from the marriage.
|
| Second Credit Card Debt | ||
| Debtor Name | Text |
Enter the name of the debtor for this credit card debt. Fill only if 'Debtor Name' has a value.
Depends on:
Debtor Name
|
| Original Debt Amount | Number |
Enter the original amount of this credit card debt. Fill only if 'Debtor Name' has a value.
Depends on:
Debtor Name
|
| Date Incurred | Date |
Enter the date when this credit card debt was incurred. Fill only if 'Debtor Name' has a value.
Depends on:
Debtor Name
|
| Debt Purpose | Text |
Enter the purpose for which this credit card debt was incurred. Fill only if 'Debtor Name' has a value.
Depends on:
Debtor Name
|
| Periodic Payment Amount | Number |
Enter the monthly or other periodic payment amount for this credit card debt. Fill only if 'Debtor Name' has a value.
Depends on:
Debtor Name
|
| Debt Amount at Commencement | Number |
Enter the amount of this credit card debt as of the date of commencement. Fill only if 'Debtor Name' has a value.
Depends on:
Debtor Name
|
| Current Debt Amount | Number |
Enter the current outstanding amount of this credit card debt. Fill only if 'Debtor Name' has a value.
Depends on:
Debtor Name
|
| Second Investment Account Details | ||
| Description | Text |
Provide a detailed description of the second investment account, security, stock option, commodity, or broker margin account.
|
| Title Holder | Text |
Enter the name of the individual or entity who holds the title for this second investment account. Fill only if 'Description' is not empty.
Depends on:
Description
|
| Location | Text |
Specify the geographic location or institution where this second investment account is held. Fill only if 'Description' is not empty.
Depends on:
Description
|
| Date of Acquisition | Date |
Enter the date when this second investment account was acquired. Fill only if 'Description' is not empty.
Depends on:
Description
|
| Source of Funds | Text |
Describe the origin or source of the funds used to acquire this second investment account. Fill only if 'Description' is not empty.
Depends on:
Description
|
| Value at Commencement Date | Number |
Enter the monetary value of this second investment account as of its commencement date. Fill only if 'Description' is not empty.
Depends on:
Description
|
| Current Value | Number |
Enter the current monetary value of this second investment account. Fill only if 'Description' is not empty.
Depends on:
Description
|
| Second Life Insurance Policy Details | ||
| Insurer's Name and Address (Policy 2) | Text |
Provide the name and full address of the insurer for the second life insurance policy. Fill only if 'Interest in any Business' is 'Yes'
|
| Name of Insured (Policy 2) | Text |
Enter the full name of the individual insured under the second life insurance policy. Fill only if 'Interest in any Business' is 'Yes'
|
| Policy Number (Policy 2) | Text |
Provide the unique policy number for the second life insurance policy. Fill only if 'Interest in any Business' is 'Yes'
|
| Face Amount of Policy (Policy 2) | Number |
Enter the face amount or death benefit of the second life insurance policy. Fill only if 'Interest in any Business' is 'Yes'
|
| Policy Owner (Policy 2) | Text |
Enter the full name of the owner of the second life insurance policy. Fill only if 'Interest in any Business' is 'Yes'
|
| Date of Acquisition (Policy 2) | Date |
Provide the date when the second life insurance policy was acquired. Fill only if 'Interest in any Business' is 'Yes'
|
| Source of Funds (Policy 2) | Text |
Describe the source of funds used to acquire the second life insurance policy. Fill only if 'Interest in any Business' is 'Yes'
|
| Cash Surrender Value at Commencement (Policy 2) | Number |
Enter the cash surrender value of the second life insurance policy as of its commencement date. Fill only if 'Interest in any Business' is 'Yes'
|
| Current Cash Surrender Value (Policy 2) | Number |
Enter the current cash surrender value of the second life insurance policy. Fill only if 'Interest in any Business' is 'Yes'
|
| Second Mortgage Payable | ||
| Mortgagee Name and Address | Text |
Please provide the full name and address of the mortgagee for the second mortgage. Fill only if 'Real Estate' is filled.
Depends on:
Description, Title Owner, Date of Acquisition, Original Price
|
| Mortgaged Property Address | Text |
Please provide the full address of the property that is mortgaged under the second mortgage. Fill only if 'Mortgagee Name and Address' is filled.
Depends on:
Mortgagee Name and Address
|
| Mortgagor(s) | Text |
Please enter the name(s) of the mortgagor(s) for the second mortgage. Fill only if 'Mortgagee Name and Address' is filled.
Depends on:
Mortgagee Name and Address
|
| Original Debt Amount | Number |
Please enter the original amount of the second mortgage debt. Fill only if 'Mortgagee Name and Address' is filled.
Depends on:
Mortgagee Name and Address
|
| Debt Incurring Date | Date |
Please provide the date when this second mortgage debt was incurred. Fill only if 'Mortgagee Name and Address' is filled.
Depends on:
Mortgagee Name and Address
|
| Periodic Payment Amount | Number |
Please enter the amount of the monthly or other periodic payment for the second mortgage. Fill only if 'Mortgagee Name and Address' is filled.
Depends on:
Mortgagee Name and Address
|
| Maturity Date | Date |
Please provide the maturity date for the second mortgage. Fill only if 'Mortgagee Name and Address' is filled.
Depends on:
Mortgagee Name and Address
|
| C31B Debt Comm | Text |
Depends on:
Mortgagee Name and Address
|
| C31B Debt Current | Text |
Depends on:
Mortgagee Name and Address
|
| Second Other Liability | ||
| Description | Text |
Provide a detailed description of the second other liability.
|
| Creditor Name and Address | Text |
Enter the name and full address of the creditor for the second other liability.
|
| Debtor | Text |
Enter the name of the debtor for this second other liability.
|
| Original Debt Amount | Number |
Enter the original amount of the debt for the second other liability.
|
| Date Incurred | Date |
Enter the date when the second other liability was incurred.
|
| Purpose | Text |
Describe the purpose for which the second other liability was incurred.
|
| Monthly or Periodic Payment | Number |
Enter the amount of the monthly or other periodic payment for the second other liability.
|
| Debt Amount at Commencement | Number |
Enter the amount of debt for the second other liability as of the date of commencement.
|
| Current Debt Amount | Number |
Enter the current outstanding amount of the second other liability.
|
| Second Other Monthly Expense | ||
| Second Other Monthly Expense Name | Text |
Please provide the name or a brief description of the second other monthly expense.
|
| Second Other Monthly Expense Amount | Number |
Please enter the monthly amount for the second other expense. Fill only if 'Second Other Monthly Expense Name' is filled.
Depends on:
Second Other Monthly Expense Name
|
| Second Real Estate Item | ||
| Description | Text |
Provide a description of the second real estate item.
|
| Title Owner | Text |
Enter the name of the owner(s) holding title to this real estate item.
|
| Date of Acquisition | Date |
Enter the date when this real estate item was acquired.
|
| Original Price | Number |
Enter the original purchase price of this real estate item.
|
| Source of Funds to Acquire | Text |
Specify the source of funds used to acquire this real estate item.
|
| Amount of Mortgage or Lien Unpaid | Number |
Enter the outstanding amount of any mortgage or lien on this real estate item.
|
| Estimated Current Fair Market Value | Number |
Provide an estimated current fair market value for this real estate item.
|
| Second Retirement Account | ||
| Second Retirement Account Description | Text |
Provide a detailed description of the second retirement account, including its type and any relevant details.
|
| Second Retirement Account Location of Assets | Text |
Enter the physical or administrative location of the assets held within the second retirement account.
|
| Second Retirement Account Title Owner | Text |
State the legal owner of the second retirement account.
|
| Second Retirement Account Date of Acquisition | Date |
Enter the date on which the second retirement account was acquired or established.
|
| Second Retirement Account Source of Funds | Text |
Specify the origin of the funds used to establish or contribute to the second retirement account.
|
| Second Rider Section | ||
| Section Number | Text |
Enter the current section number of the rider. Fill only if 'Number of rider pages' is greater than 0.
Depends on:
Rider Page Count
|
| Rider Section Content | Text |
Provide the detailed content for this section of the rider. Fill only if 'Section Number' is not empty.
Depends on:
Section Number
|
| Second Savings Account | ||
| Financial Institution | Text |
Enter the name of the financial institution where the second savings account is held. Fill only if 'Financial Institution' is filled.
Depends on:
Financial Institution
|
| Account Number | Text |
Enter the account number for the second savings account. Fill only if 'Financial Institution' is filled.
Depends on:
Financial Institution
|
| Title Holder | Text |
Enter the name(s) of the individual(s) or entity holding the title to the second savings account. Fill only if 'Financial Institution' is filled.
Depends on:
Financial Institution
|
| Type of Account | Text |
Enter the specific type of the second savings account (e.g., individual, joint, trust, certificate of deposit). Fill only if 'Financial Institution' is filled.
Depends on:
Financial Institution
|
| Date Opened | Date |
Enter the date when the second savings account was opened. Fill only if 'Financial Institution' is filled.
Depends on:
Financial Institution
|
| Source of Funds | Text |
Enter the origin or source of the funds deposited into the second savings account. Fill only if 'Financial Institution' is filled.
Depends on:
Financial Institution
|
| Balance as of Commencement Date | Number |
Enter the balance of the second savings account as it was on the date of commencement. Fill only if 'Financial Institution' is filled.
Depends on:
Financial Institution
|
| Current Balance | Number |
Enter the current balance of the second savings account. Fill only if 'Financial Institution' is filled.
Depends on:
Financial Institution
|
| Second Vehicle Details | ||
| Second Vehicle Description | Text |
Enter a detailed description of the second vehicle, including its type, make, and model.
|
| Second Vehicle Title Owner | Text |
Provide the name of the person or entity who holds the legal title to the second vehicle.
|
| Second Vehicle Acquisition Date | Date |
Enter the date on which the second vehicle was acquired.
|
| Second Vehicle Original Price | Number |
Enter the initial purchase price of the second vehicle.
|
| Second Vehicle Source of Funds | Text |
Describe how the funds were obtained to acquire the second vehicle.
|
| Second Vehicle Unpaid Lien Amount | Number |
Enter the outstanding amount of any lien against the second vehicle.
|
| Second Vehicle Current Fair Market Value | Number |
Enter the estimated fair market value of the second vehicle at the present time.
|
| Second Vehicle Value at Commencement | Number |
Enter the value of the second vehicle as of the specified date of commencement.
|
| Seventh Rider Section | ||
| Section Identifier | Text |
Enter the specific identifier or number for this rider section. Fill only if 'Number of rider pages' is greater than 0.
Depends on:
Rider Page Count
|
| Section Content | Text |
Provide the detailed content or additional information for this rider section. Fill only if 'Section Identifier' is not empty.
Depends on:
Section Identifier
|
| Sixth Rider Section | ||
| Sixth Section Number | Text |
Please enter the numerical identifier for the sixth section of the Rider. Fill only if 'Number of rider pages' is greater than 0.
Depends on:
Rider Page Count
|
| Sixth Section Content | Text |
Please provide the detailed content for the sixth section of the Rider. Fill only if 'Sixth Section Number' is not empty.
Depends on:
Sixth Section Number
|
| Social Security Benefits | ||
| Social Security Benefits Amount | Number |
Please enter the amount received from Social Security benefits.
|
| Source of funds to acquire | ||
| Source of Funds | Text |
Please provide a detailed explanation of the source of funds used to acquire the business interest. Fill only if 'Interest in any Business' is 'Yes'
|
| Statement Identification | ||
| Statement Number | Text |
Provide the identification number for this Statement of Net Worth.
|
| Supplemental Security Income | ||
| Supplemental Security Income Amount | Number |
Provide the amount received from Supplemental Security Income, to the extent not already included in gross income.
|
| Taxes Payable | ||
| Description of Tax | Text |
Please enter a description of the tax.
|
| Amount of Tax | Number |
Please enter the amount of the tax.
|
| Date Due | Date |
Please enter the date the tax is due.
|
| Total Taxes Payable | Number |
Please enter the total amount of all taxes payable.
|
| Tenth Rider Section | ||
| Tenth Rider Section Number | Text |
Enter the numeric identifier for the tenth rider section. Fill only if 'Number of rider pages' is greater than 0.
Depends on:
Rider Page Count
|
| Tenth Rider Section Content | Text |
Provide the complete content and details for this tenth rider section. Fill only if 'Tenth Rider Section Number' is not empty.
Depends on:
Tenth Rider Section Number
|
| Third Other Monthly Expense | ||
| Third Other Monthly Expense Name | Text |
Please enter the name or description of the third other monthly expense.
|
| Third Other Monthly Expense Amount | Number |
Please provide the monthly amount for the third other expense. Fill only if 'Third Other Monthly Expense Name' is filled.
Depends on:
Third Other Monthly Expense Name
|
| Third Rider Section | ||
| Rider Section Identifier | Text |
Provide the identifier or number for the section you are adding to the Rider. Fill only if 'Number of rider pages' is greater than 0.
Depends on:
Rider Page Count
|
| Rider Section Content | Text |
Enter the content or additional details for this Rider section. Fill only if 'Rider Section Identifier' is not empty.
Depends on:
Rider Section Identifier
|
| Total Accounts | ||
| Total Savings Accounts | Number |
Provide the total monetary value for all savings accounts.
|
| Total Accounts | Number |
Provide the grand total monetary value for all listed accounts.
|
| Total Accounts Payable | ||
| Total Accounts Payable | Number |
Please provide the total amount for all accounts payable.
|
| Total Assets | ||
| Total Assets | Number |
Provide the total value of all assets.
|
| Total Automotive Expense | ||
| Total Monthly Automotive Expense | Number |
Please provide the total monthly expenditure for all automotive costs. Fill only if 'Automotive insurance' has a value.
Depends on:
Automotive Insurance Monthly Cost
|
| Total Cash Surrender Value of Life Insurance | ||
| Total Cash Surrender Value | Number |
Please provide the total cash surrender value of life insurance. Fill only if 'Interest in any Business' is 'Yes'
|
| Total Checking Accounts | ||
| Total Checking Accounts | Number |
Please provide the total amount for all checking accounts.
|
| Total Credit Card Debt | ||
| Total Credit Card Debt | Number |
Please provide the total amount of all credit card debt.
|
| Total Home Equity and Other Lines of Credit | ||
| Total Home Equity and Other Lines of Credit | Number |
Provide the total dollar amount for Home Equity and Other Lines of Credit.
|
| Total Installment Accounts | ||
| Total Installment Accounts | Number |
Please enter the total amount for all installment accounts.
|
| Total Liabilities | ||
| Total Liabilities Amount | Number |
Please enter the grand total amount of all liabilities.
|
| Total Loans to Others and Accounts Receivable | ||
| Total Loans and Accounts Receivable | Number |
Provide the total amount of all loans to others and accounts receivable. Fill only if 'Amount Due as of Commencement Date', 'Current Amount Due' is calculated from fields 'Amount due as of date of commencement' and 'Current amount due' for all loans.
Depends on:
Amount Due as of Commencement Date, Current Amount Due
|
| Total Miscellaneous | ||
| Total Miscellaneous | Number |
Enter the total amount for all miscellaneous expenses listed.
|
| Total Monthly Expenses | ||
| Total Monthly Expenses | Number |
Provide the total sum of all monthly expenses.
|
| Total Mortgages Payable | ||
| Total Mortgages Payable | Number |
Provide the total amount of all mortgages payable. Fill only if 'Current Debt Amount', 'C31B Debt Current' is filled.
Depends on:
Current Debt Amount, C31B Debt Current
|
| Total Other | ||
| Total Other | Number |
Enter the total amount for other monthly expenses.
|
| Total Other Liabilities | ||
| Total Other Liabilities | Number |
Provide the total amount for all other liabilities listed.
|
| Total Real Estate | ||
| Total Real Estate Value | Number |
Please provide the total estimated value of all real estate assets.
|
| Total Value of Business Interests | ||
| Total Value of Business Interests | Number |
Please provide the total monetary value of all business interests. Fill only if 'Interest in any Business' is 'Yes'
|
| Total Value of Jewelry, Art, Antiques, etc. | ||
| Total Value of Jewelry, Art, Antiques, etc. | Number |
Please provide the total combined value for all jewelry, art, antiques, household furnishings, precious objects, gold, and precious metals listed.
|
| Total Value of Vehicles | ||
| Total Value of Vehicles | Number |
Provide the total monetary value of all vehicles.
|
| Twelfth Rider Section | ||
| Section Number | Text |
Enter the number or identifier for this specific section of the twelfth rider. Fill only if 'Number of rider pages' is greater than 0.
Depends on:
Rider Page Count
|
| Twelfth Rider Section Content | Text |
Provide the detailed content for this twelfth rider section. Fill only if 'Section Number' is not empty.
Depends on:
Section Number
|
| Unemployment Insurance Benefits | ||
| Unemployment Insurance Benefits | Number |
Please enter the total amount received for unemployment insurance benefits.
|
| Unreimbursed Business Expenses | ||
| Unreimbursed Business Expenses | Number |
Enter the total amount of your unreimbursed business expenses. Fill only if 'Automobile Business Use' is 'Yes'.
Depends on:
Business
|
| Unreimbursed Medical Expenses | ||
| Medical | Number |
Enter the monthly unreimbursed medical expenses.
|
| Dental | Number |
Enter the monthly unreimbursed dental expenses.
|
| Optical | Number |
Enter the monthly unreimbursed optical expenses.
|
| Pharmaceutical | Number |
Enter the monthly unreimbursed pharmaceutical expenses.
|
| Surgical, Nursing, Hospital | Number |
Enter the monthly unreimbursed surgical, nursing, or hospital expenses.
|
| Psychotherapy | Number |
Enter the monthly unreimbursed psychotherapy expenses.
|
| Other Unreimbursed Medical | Number |
Enter any other monthly unreimbursed medical expenses not listed above.
|
| Total Unreimbursed Medical | Number |
Enter the total monthly unreimbursed medical expenses.
|
| Veterans Benefits | ||
| Veterans Benefits | Number |
Provide the total amount of veterans benefits received.
|
| Worker's Compensation | ||
| Worker's Comp Lost Wages Percentage | Number |
Enter the percentage of the worker's compensation amount that is due to lost wages. Fill only if 'Worker's Comp Total Amount' is filled.
Depends on:
Worker's Comp Total Amount
|
| Worker's Comp Total Amount | Number |
Enter the total amount received for worker's compensation.
|