Financial Disclosure Affidavit - Nyc
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2OCSE-388 (E) 11/2008
Rev. 05/2016
F.C.A. §§ 413-1, 424-a; Art. 5-B
D.R.L. §§ 236-B, 240
Docket #:
File #:
Income and Expenses Statement
This form is used to give the court information about your financial situation.
Complete both pages of this form. Sign it only if you’re in front of a notary.
Bring the following to your next court date:
This form
Copy of your W-2s and/or 1099 statements
Copy of your two (2) most recent pay stubs
Bring all documents to prove the amount of other
Copy of your most recent tax returns, federal
income and/or debt and loans
and state or IRS letter that shows that you do
Proof of health insurance coverage (insurance card)
not have to file taxes
Proof of public assistance
Name: _____________________________________
Date of Birth: _____________
Child’s Name
Child’s Date of Birth
Child Lives With
☐
☐
Are you paying additional child support orders?
Yes
No
How much? $ ___________ To whom? _____________________________
☐
☐
Income: Are you self-employed?
Yes
No
Employer: __________________________________ Hours worked per week: _______
Address: ______________________________________________________________
Gross weekly salary or wage: $___________________
Income from other sources:
$___________________
(public assistance, rent, part-time job, tips, dividends, etc.)
Income from other household members: $___________________
Health Insurance Coverage
My insurance coverage is ☐ through my job ☐ privately purchased ☐ Medicaid
☐ I don’t have health insurance coverage.
My coverage includes ☐ Medical ☐ Dental ☐ Vision ☐ Prescription ☐ All
Insurance Plan Name: ____________________________ Policy #: ________________
I pay/contribute $___________ ☐ weekly ☐ every two weeks ☐ monthly
☐ for a Family Plan.
☐ for an Individual Plan. A Family Plan would cost $_________ ☐ weekly ☐ every
two weeks ☐ monthly
The child(ren)’s health insurance is covered by ☐ my plan ☐ the other parent’s plan
☐ Child Health Plus ☐ Medicaid ☐ Private Insurance: _____________________
Financial Disclosure Affidavit – Short version
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