____, the (Petitioner) (Respondent) (Plaintiff) (Defendant) herein, being duly sworn, deposes and says that the following is an accurate statement as of __, of my net worth (assets of whatsoever kind and nature and wherever situated minus liabilities), statement of income from all sources and statement of assets transferred of whatsoever kind and nature and wherever situated:

I. FAMILY DATA:

(a) Husband's age __

(b) Wife's age __

(c) Date married __

(d) Date (separated) (divorced) __

(e) Number of dependent children under 21 years __

(f) Names and ages of children ____________ ____________ ____________ ____________

(g) Custody of children __ Husband __ Wife

(h) Minor children of a prior marriage: __ Husband __ Wife

(i) (Husband)(Wife) (paying)(receiving) $_ as alimony (maintenance) and/or $ _ child support in connection with prior marriage

(k) Is marital residence occupied by Husband __ Wife __ Both __

II. EXPENSES: (You may elect to list all expenses on a weekly basis or all expenses on a monthly basis, however, you must be consistent. If any items are paid on a monthly basis, divide by 4.3 to obtain weekly payments; if any items are paid on a weekly basis, multiply by 4.3 to obtain monthly payment. Attach additional sheet, if needed. Items included under “Other” should be listed separately with separate dollar amounts.)

(j) Automotive

Year: __ Make: ___ Personal: __ Business: __

Year: __ Make: ___ Personal: __ Business: __

Year: __ Make: ___ Personal: __ Business: __

III. GROSS INCOME: (State source of income and annual amount. Attach additional sheet, if needed.)

(a) Salary or wages: (State whether income has changed during the year preceding date of this affidavit __. If so, set forth name and address of all employers during preceding year and average weekly wage paid by each. Indicate overtime earnings separately. Attach previous year's W-2 or income tax return.)

(c) Social Security number ________

(d) Number and names of dependents claimed: ____

IV. ASSETS. (If any asset is held jointly with spouse or another, so state, and set forth your respective shares. Attach additional sheets, if needed.)

A. Cash accounts

Cash

Checking accounts

Savings accounts (including individual, joint, totten trust, certificates of deposit, treasury notes)

Security deposits, earnest money, etc.

Other

B. Securities

Bonds, notes, mortgages

Total: Bonds, notes, etc. $__

Stocks, options and commodity contracts

Broker margin accounts

C. Loans to others and accounts receivable

D. Value of interest in any business

E. Cash surrender value of life insurance

F. Vehicles (automobile, boat, plane, truck, camper, etc.)

G. Real estate (including real property, leaseholds, life estates, etc. at market value—do not deduct any mortgage)

H. Vested interests in trusts (pension, profit sharing, legacies, deferred compensation and others)

I. Contingent interests (stock options, interests subject to life estates, prospective inheritances, etc.)

J. Household furnishings

K. Jewelry, art, antiques, precious objects, gold and precious metals (only if valued at more than $500)

L. Other (e.g., tax shelter investments, collections, judgments, causes of action, patents, trademarks, copyrights, and any other asset not hereinabove itemized)

V. LIABILITIES

A. Accounts payable

B. Notes payable

C. Installment accounts payable (security agreements, chattel mortgages)

D. Brokers’ margin accounts

E. Mortgages payable on real estate

F. Taxes payable

G. Loans on life insurance policies

H. Other liabilities

VI. ASSETS TRANSFERRED: (List all assets transferred in any manner during the preceding three years, or length of the marriage, whichever is shorter [transfers in the routine course of business which resulted in an exchange of assets of substantially equivalent value need not be specifically disclosed where such assets are otherwise identified in the statement of net worth].)

VII. SUPPORT REQUIREMENTS:

(b) Deponent requests for support of each child $ __ per (week)(month). Total for children $ __ .

(c) Deponent requests for support of self $ __ per (week)(month).

(d) The day of the (week)(month) on which payment should be made is __ .

VIII. COUNSEL FEE REQUIREMENTS:

(a) Deponent requests for counsel fee and disbursements the sum of $ __ .

(c) There is (not) a retainer agreement or written agreement relating to payment of legal fees. (A copy of any such agreement must be annexed.)

IX. ACCOUNTANT AND APPRAISAL FEES REQUIREMENTS:

(a) Deponent requests for accountants' fees and disbursements the sum of $ __. (Include basis for fee, e.g., hourly rate, flat rate.)

(b) Deponent requests for appraisal fees and disbursements the sum of $ __ . (Include basis for fee, e.g., hourly rate, flat rate.)

X. Other data concerning the financial circumstances of the parties that should be brought to the attention of the Court are:

The foregoing statements and a rider consisting of __ page(s) annexed hereto and made part hereof, have been carefully read by the undersigned who states that they are true and correct.

Sworn to before me this __ day of __, 19_

SIGNATURE OF ATTORNEY

ATTORNEY’S NAME (PRINT OR TYPE

______________ ______________ ______________

ATTORNEY’S ADDRESS AND TELE- PHONE NUMBER