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Law Office of Theresa A. Markham, P.C.

Printer-Friendly Case Information Statement

TO OUR CLIENTS: This is the Case Information Statement. You can either,

1. Print it and complete it by hand, and then mail it to us, OR
2. Select all text and Copy it to your Word Processing Program and enter the data directly into the form on your computer, then e-mail the document to us or print the completed form and mail it to us.
3. Note: An attorney-client relationship is not created by submitting this form to us. We do not become your attorneys until you have signed a retainer agreement.

Attorney(s): Emmons & Markham, P.C.

Office Address & Tel. No.: 529 Route 515, Ste. 201, Vernon NJ 07462 (973)764-8811

Attorney(s) for:

		SUPERIOR COURT OF NEW JERSEY
	Plaintiff	CHANCERY DIVISION, FAMILY PART
v.		COUNTY
		DOCKET NO.
	Defendant
		CASE INFORMATION STATEMENT OF

PART A – CASE INFORMATION	ISSUES IN DISPUTE:
Date of Statement	Cause of Action
Date of Prior Statement:	Custody
Your Birthdate	Alimony
Birthdate of Spouse	Child Support
Date of Marriage	Equitable Distribution
Date of Separation	Counsel Fees
Date of Complaint	Other

Does an agreement exist between parties relative to any issue? [ ] Yes [ ] No. If Yes, attach a copy (if written) or a summary (if oral).

1. Names and Addresses of Parties:
Your Name
Street Address				State/Zip
Other Party’s Name
Street Address				State/Zip
2. Name, Address & Birthdate of all Child(ren); Person with whom Child(ren) Reside(s):
Child’s Full Name	Address	Birthdate	Person’s Name

PART B – MISCELLANEOUS INFORMATION:
1. Names and Address of Your Employer (Provide Name & Address of Co. if Self-Employed)
Name of Employer			Address
Name of Employer
2. Name and Address of Your Health Insurance Company(ies); Policy Information:
Name of Company			Address
ID Number			Group Number
Coverage Type:	Single [ ] Parent-Child [ ] Family [ ] Optical [ ]
	Hospital [ ] Major-Medical [ ] Dental [ ] Drug [ ] Diagnostic [ ]
Check if made available through employment [ ]		Or personally obtained [ ]

Name of Company			Address
ID Number			Group Number
Coverage Type:	Single [ ] Parent-Child [ ] Family [ ] Optical [ ]
	Hospital [ ] Major-Medical [ ] Dental [ ] Drug [ ] Diagnostic [ ]
Check if made available through employment [ ]		Or personally obtained [ ]

3. Name(s) and Address(es) of Life Insurance Company(ies); Policy Information:
Name of Company		Address
Policy Number		Beneficiary
Face Amount $		Name of Insured
Policy Owner		2^nd Beneficiary
Name of Company		Address
Policy Number		Beneficiary
Face Amount $		Name of Insured
Policy Owner		2^nd Beneficiary
4. Additional Identification:	Social Security Number
State Driver’s License Number:			Eye Color:
5. Attach sheet listing all prior/pending family actions involving support, custody or domestic violence listing Docket Number, County, State and the Disposition reached. Comments:

PART C – INCOME INFORMATION: Complete this section for self and (if known) for spouse. Attach to this form a corporate benefits statement as well as a statement of all fringe benefits of employment.
	I. LAST YEAR’S INCOME
		Yours	Joint	Spouse or Former Spouse
1. Gross earned income last calendar
2. Unearned income (same year)
3. Total Income Taxes paid on income (incl. Fed., State, FICA, and SUI) If Joint Return, use middle column.
4. Net Income (1+2-3)

Attach a full and complete copy of last year’s Federal and State Income Tax Returns. If non has been filed, attach W-2 statements, 1099’s, Schedule C’s, etc., to show total income plus a copy of the most recently filed Tax Returns.

Check if attached: Federal Tax Return [ ] State Tax Return [ ] W-2 [ ] Other [ ]

2. PRESENT EARNED INCOME AND EXPENSES

	Yours	Spouse (if known)
1. Average Gross monthly income (based on last 3 pay periods – attach pay stubs) Commissions and bonuses, etc., are: [ ] included* [ ] not included* [ ] not paid to you. Comments:
*Attach details of basis thereof, including by not limited to, percentage overrides, timing of payments, etc. Attach copies of last three statements of such bonuses, commissions, etc.
2. Deductions per month (check all types of withholdings):
[ ] Federal [ ] State [ ] F.I.C.A. [ ] S.U.I. [ ] Other
3. Net Income (1 – 2)
Comments

PART C-3. YOUR YEAR-TO-DATE INCOME							Provide Dates: From to
1. GROSS EARNED INCOME						Number of Weeks
2. TAX DEDUCTIONS	(Number of dependents: )
a. Federal Income Taxes			a. $
b. N.J. Income Taxes			b. $
c. FICA			c. $
d. S.U.I			d. $
e. Estimated tax payments in excess of withholding actually made			e. $
f.			f. $
g.			g. $
		TOTAL $
3. GROSS INCOME NET OF TAXES			$
4. OTHER DEDUCATIONS							If mandatory, check box
a. Hospitalization/Medical Insurance			a. $		[ ]
b. Life Insurance			b. $		[ ]
c. Pension/Profit Sharing Plans			c. $		[ ]
d. Savings/Bond plan			d. $		[ ]
e. Wage Execution			e. $		[ ]
f. Retirement Fund Payment			f. $		[ ]
g. Other:			g. $		[ ]
		TOTAL $
5. NET YEAR-TO-DATE EARNED INCOME $
NET AVERAGE EARNED INCOME PER MONTH $
6. GROSS UNEARNED INCOME
Source				How Often Paid				Year to date Amount
TOTAL GROSS UNEARNED INCOME YEAR TO DATE $

PART D – MONTHLY EXPENSES (computed at 4.3 wks/mo.) Should reflect standard of living established during marriage, but not repeat those income deductions listed on Part C.
	Yours and children (__) residing with you	Expenses paid for spouse and/or children (__) not residing with you
SHEDULE A: SHELTER
If Tenant:
Rent $
Heat (if not furnished)
Electric & Gas (if not furnished)
Renter’s Insurance
Parking (at Apartment)
Other Charges (Itemize)
If Homeowner:
Mortgage $
Real Estate Taxes (unless included w/mort. payment)
Homeowner’s Insurance (unless included w/mort. Pymt)
Repairs & Maintenance
Heat (unless Electric or Gas)
Electric & Gas
Water & Sewer
Garbage Removal
Other Mortgages (Specify)
Snow Removal & Lawn Care
Maintenance (Condo/co-op)
Other Charges (Itemize)