Child Support Emancipation Questionnaire

KENNETH VERCAMMEN & ASSOCIATES, PC ATTORNEY AT LAW www.kennethvercammen.com Child Support Emancipation Questionnaire Please fill out and return to our Office. (Please Print) NAME __________________________________________________________ ADDRESS _______________________________________________________ CITY ___________________________ STATE _______ ZIP _______________ CELL-PHONE ___________________________________ (Area Code Needed) PHONE-DAY ________________________ NIGHT _______________________ E-MAIL ADDRESS _________________________________________________ TYPE OF MATTER: ________________________________________________ ADVERSARY PARTIES IF ANY: ________________________________________ REFERRED BY: ___________________________________________________ If referred by a person, is this a client or attorney? If internet, which search engine & terms used. TODAY’S DATE: ___________________________ DESCRIPTION OF MATTER (USE BACK OF PAPER IF NECESSARY): QUESTIONS TO ASK ATTORNEY: ______________________________________ Child Support EmancipationQuest non PI G3 rev 5/13/08 The Court now requires this information on a Motion: Revised Family Part Case Information Statement NOTICE: Under NJ. Court Rule. 5:5-2, this Statement must be fully completed, filed and served, with all required attachments, in accordance with Court Rule 5:5-2 based upon the information available. If the Motion is for reduction in child support and not termination of child support, a complete case information statement must be filed. In those cases where the Case Information Statement is required, it shall be filed within 20 days after the filing of the Answer or Appearance. Failure to file a Case Information Statement may result in the dismissal of a party’s pleadings. PART A - CASE INFORMATION: Date of Statement ________________ Date of Divorce (post-Judgment matters): Date(s) of Prior Settlement Statement(s): ________________ ________________ Your Birthdate: _______________ Birthdate of Spouse: ___________ Date of Marriage: _____________ Date of Divorce Complaint: ______ Does an agreement exist between parties relative to any issues? Yes _____ No ________ If yes, ATTACH a copy (if written) or a summary (if oral) 1. Name and Address of Parties: Other Partys Name: _______________________________________ Street address ______________________City ______ State/Zip _____ 2. Name, Address, & Birthdate of all Child(ren); Person with whom Child(ren) Resides: a. Child(ren) From This Relationship Childs Full Name Address Birthdate Who living with _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ b. Child(ren) From Other Relationships Childs Full Name Address Birthdate Persons Name _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ PART B - MISCELLANEOUS INFORMATION: 1. Name and Address of Your Employer (Name and Address of Business if Self-Employed) Name of Employer _____________ Address: ________________ - STATEMENT OF SPECIAL PROBLEMS (Provide a Brief Narrative Statement of Any Special Problems Involving This Case): As example, state if the matter involves complex valuation problems (such as for a closely held business) or special medical problems of any family member, etc. I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment. DATED: ________________________________ SIGNED: ________________________________ IF THE MOTION IS TO REDUCE CHILD SUPPORT, THE COURT WILL REQUIRE YOU ATTACH THE FOLLOWING REQUIRED DOCUMENTS: 1. A full and complete copy of your last federal and state income tax returns with all schedules and attachments. ___________ 2. Your last calendar years W-2 statement and 1099s. ___________ 3. Your three most recent pay stubs. ___________ 4. Bonus information including, but not limited to, percentage overrides, timing of payments, etc.; the last three statements of such bonuses, commissions, etc. ___________ 5. Your most recent corporate benefit statement or a summary thereof, showing the nature, amount and status of retirement plans, savings plans, income deferral plans, insurance benefits, etc. ___________ 6. Any agreements between the parties. ___________ 7. A statement of prior/pending cases. (Part B-4). ___________ 8. Health Insurance and Life Insurance Information. ___________ Is Insurance available through Employment/Business? Yes No Explain: __________ ADDITIONAL INFORMATION-REQUIRED IF MOTION If motion is to reduce child support and not a motion for termination, all the following information must be provided to the court. 1. How often are you paid? 2. What is your annual salary? 3. Have you received any raises in the current year? ( ) Yes ( ) No If yes, provide the date and the gross/net amount. 4. Do you receive bonuses, commissions, or other compensations, including distributions, taxable or non-taxable, in addition to your regular salary? ( ) Yes ( ) No If yes, explain: 5. Do you receive bonuses, commissions, or other compensations, including distributions, taxable or non-taxable, in addition to your regular salary during the current or immediate past calendar year? ( ) Yes ( ) No If yes, explain: 6. Do you receive cash or distributions not otherwise listed? ( ) Yes ( ) No If yes, explain: 7. Have you received income from overtime work during either the current or immediate past calendar year? ( ) Yes ( ) No If yes, explain: 8. Have you been awarded or granted stock options, restricted stock or any other non-cash compensation or entitlement during the current or immediate past calendar year? ( ) Yes ( ) No If yes, explain: 9. Have you received any other supplemental compensation during either the current or immediate past calendar year? ( ) Yes ( ) No If yes, state the date(s) of receipt and set forth the gross and net amounts received. Also describe the nature of any supplemental compensation received. 10. Have you received income from unemployment, disability and/or social security during either the current or immediate past calendar year? ( ) Yes ( ) No If yes, state the date(s) of receipt and set forth the gross and net amounts received. 11. List the names of the dependents you claim: 12. Are you paying or receiving any alimony? ( ) Yes ( ) No If yes, how much and to whom paid or from whom received? 13. Are you paying or receiving any child support? ( ) Yes ( ) No If yes, list names of children, the amount paid or received for each child and to whom paid or from whom received. 14. Is there a wage execution in connection with support? ( ) Yes ( ) No If yes, explain. 15. Has a dependent child of yours received income from social security, SSI or other government program during either the current or immediate past calendar year? ( ) Yes ( ) No If yes, explain the basis and state the date(s) of receipt and set forth the gross and net amounts received. 16. Explanation of Income or Other Information: Child Support EmancipationQuest non PI G3

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