General Instructions

• Complete every section. If something does not apply to you, write "N/A" instead of leaving it blank.
• Be honest and accurate. The form is a sworn statement, and incorrect information can have legal consequences.
• Do not guess. If you are unsure of a number, check your records or write "Unknown - information available to spouse."
• Attach supporting documents. Many sections require proof such as tax returns, bank statements, and pay stubs.
• Take your time. You will likely need to gather information over multiple sittings.

Section-by-Section Instructions

Part I: Family Data

This section collects basic information about you, your spouse, and your children.

• Your Full Name, Date of Birth, and Address
• Spouse's Full Name, Date of Birth, and Address
• Date of Marriage
• Names and Birthdates of All Children (from this or prior marriages)
• Who has custody of children from prior marriages (if applicable)
• Your Employer, Job Title, and Employer's Address
• Spouse's Employer, Job Title, and Employer's Address

Documents to Attach: None required for this section.

Part II: Monthly Expenses

You must provide monthly amounts for each expense. If you are unsure, review your bills or bank statements.

(a) Housing

• Mortgage Payment – If you own a home, write the exact monthly mortgage payment.
• Property Taxes – If included in your mortgage, check your statement. If paid separately, divide the annual tax bill by 12.
• Homeowner's Insurance – If included in your mortgage, check your statement. If paid separately, divide the annual amount by 12.
• Home Equity Loan/Second Mortgage – List the monthly payment amount.
• Rent Payment – If renting, write the exact monthly rent amount.
• HOA/Condo Fees – If applicable, write the monthly fee and any special assessments.

Documents: Mortgage statements, property tax bills, insurance policies, lease agreements.

(b) Utilities

Calculate the average monthly cost for each utility:

• Electricity, Gas, Water, Sewer, Trash Collection – Add up 12 months of bills and divide by 12.
• Landline, Internet, Cable/Satellite TV – If bundled, note that on the form.
• Cell Phone - Indicate who is included in the bill (e.g., "Myself and two children").
• Other Services – Include Netflix, Hulu, Amazon Prime, etc.

Documents: Utility bills from the last 12 months.

(c) Food

• Groceries - Multiply your weekly grocery bill by 52, then divide by 12.
• Dining Out/Takeout – Estimate based on past spending.

Documents: Grocery receipts, credit card statements.

(d) Clothing

• Your Clothing Costs – Include regular purchases and seasonal expenses.
• Children's Clothing – Consider back-to-school shopping, coats, and shoes.
• Dry Cleaning – List monthly costs if applicable.

(e) Insurance

• Life Insurance – Indicate whether it is paid through payroll deductions or directly.
• Auto Insurance – Divide the 6- or 12-month premium by 6 or 12 to get the monthly amount.
• Medical, Dental, Optical Insurance – If deducted from payroll, multiply the per-paycheck amount by the number of pay periods per year and divide by 12.

Documents: Insurance policy statements.

(f) Unreimbursed Medical Expenses

• Prescriptions – Request a yearly total from your pharmacy and divide by 12.
• Doctor Visits – Multiply the number of visits by your co-pay and divide by 12.
• Psychotherapy – Multiply weekly co-pays by 52 and divide by 12.

Documents: Medical bills, pharmacy statements.

(g) Household Maintenance

• Repairs, Landscaping, Snow Removal, Pest Control – Estimate yearly total and divide by 12.
• Sanitation - if you pay for private garbage company

(h) Household Help

• Babysitters, Nannies, Housekeepers – Multiply weekly payments by 52 and divide by 12.

(i) Automobile

• Loan/Lease Payments – Indicate loan term (e.g., 36 or 60 months).
• Gas & Oil – Estimate based on fuel costs and frequency of refueling.
• Tolls & Parking – Use past 12 months' EZ Pass or parking expenses.

Documents: Car loan statements, insurance policies.

(j) Education

• Tuition - Include amounts paid for private school, college, or religious instruction. Take the annual tuition and divide by 12. For college and post-graduate tuition, do not include contributions to 529 accounts, student loan payments or parent loan payments.
• School Supplies, Books, Lunches – Estimate annual expenses and divide by 12.
• Transportation – Include this amount if you pay for transportation to the provider. If its paid by your school district, put N/A in this section.
• School Events – These are school events that you pay for, such as a dance or class trip.
• Other - the cost of a tutor would go in this section

Documents: Tuition bills, receipts.

(k) Recreation

• Vacations, Gym Memberships, Birthday Parties, Entertainment – Estimate yearly spending and divide by 12.
• Music Subscriptions – List monthly fees for Spotify, Apple Music, etc.
• Summer Camp – Divide total camp cost by 12.

(l) Income Taxes

Look at your most recent W2

• Federal - Box 2 divided by 12.
• State – Box 17 divided by 12
• City (if any) – Box 19 divided by 12
• Social Security and Medicare – add box 4 and box 6, then divide by 12

(m) Miscellaneous

Total up the cost per year for each member of your family, and divide by 12.

• Veterinarian/Pet Expenses - include the cost of visits, medications, food, etc and divide the cost by 12.
• Child Support Payments – Only if you pay children child support for OTHER children
• Alimony or Maintenance Payments – Only if you pay spousal support to someone OTHER than your current spouse
• Loan Payments – include loan payments not already listed in expenses.

Part III: Gross Income

List all sources of YOUR income, including:

• Salary and Wages – Use Box 5 from your W-2. If you have multiple W2's, list each one separately.
• Bonuses, Commissions, Rental Income, Investment Income – List exact amounts.
• Child Support or Spousal Maintenance Received – Do NOT include support from your current spouse.

Documents: Pay stubs (last 3 months), tax returns (last 3 years).

Part IV: Assets

List everything you own that is of value:

1. Cash and Bank Accounts – Provide details for checking, savings, and CDs. If you have more than one account, list them separately. Use additional sheets if necessary.
2. Real Estate – List all properties with their estimated market value. (e.g., co-op, condo, investment properties, vacation homes, life estates)
3. Retirement Accounts – List ALL 401(k), IRA, pension, etc. for both you and your spouse. Use additional sheets if necessary.
4. Vehicles – List ALL cars, boats, motorcycles, planes, trucks, campers ,jet skis, quads, etc owned by you and your spouse. Include year, make, model, mileage, purchase price, condition and features. Do not include leased vehicles.
5. Jewelry, Art, Antiques, Precious Metals – Only list items worth over $500.
6. Business - If you or your spouse own a business, list it here
7. Cash Surrender of Life Insurance - only complete this section if you life insurance has cash value now.
8. Investments – Include stocks, bonds, and brokerage accounts.
9. Loans to Others – Include formal loans and informal loans owed to you or your spouse from friends ,family or customers.
10. Contingent Interests – Include stock options, future commissions or fees.
11. Other Assets – This includes intellectual property, potential claims, or judgements against other people

Documents: Bank statements, property deeds, retirement account statements.

Part V: Liabilities

List all debts, including:

1. Accounts Payable – Include overdue rent, country club memberships, car services, exterminators, plumbers, gardeners, or any other businesses where you owe money.
2. Credit Card Debt – List current balances and minimum payments for your credit cards and your spouses credits cards. Use additional sheets if necessary
3. Mortgages Payable on Real Estate – Include mortgages on all properties. HELOC are listed in the next section.
4. Home Equity and Other Lines of Credit – Include all properties
5. Notes Payable – This includes personal loans from a bank, family member or friend
6. Brokers' Margin Account – If you purchased securities on margin, list it here.
7. Taxes Payable – List any back taxes owed
8. Loans on Life Insurance Policies – Include money borrowed against life insurance policies.
9. Installment Accounts Payable – List all vehicle loans
10. Other Liabilties -e.g. student loans List amounts owed

Documents: Loan agreements, credit card statements.

Part VI: Assets Transferred

If you transferred an asset (such as a vehicle or property), include it here.

Final Steps

• Review your entries. Ensure accuracy.
• Attach required documents.
• Sign in front of a notary.

By carefully completing this form, you provide the court with a clear financial picture, helping to ensure a fair outcome in your case.