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Part A Part B Part C Part D Part E Part F

CIS - PART A
WIFE'S ADDRESS 		*Press Tab Key to Move From Field to Field
Wife's First Name
Wife's Middle Name
Wife's Last Name
Wife's Street Address
Wife's City
Wife's State/Province
Wife's Zip/Postal Code
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CIS - PART A
HUSBAND'S PARTY'S ADDRESS 		*Press Tab Key to Move From Field to Field
Husband's First Name
Husband's Middle Name
Husband's Last Name
Husband's Street Address
Husband's City
Husband's State/Province
Husband's Zip/Postal Code
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CIS - PART A
IMPORTANT DATES 		*Press Tab Key to Move From Field to Field
If you do not know a date below, leave it blank
Enter the date of this Statement: -- mm/dd/yyyy
Enter the date of Divorce: -- mm/dd/yyyy
Enter the date of Prior CIS (if any): -- mm/dd/yyyy
Enter your Birth date: -- mm/dd/yyyy
Other Party's Birth date: -- mm/dd/yyyy
Enter the date of Marriage: -- mm/dd/yyyy
Enter the date of Separation: -- mm/dd/yyyy
Enter the date of Complaint: -- mm/dd/yyyy
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CIS - PART A
ISSUES IN DISPUTE 		*Press Tab Key to Move From Field to Field
Place the letter X in one or more boxes below to indicate the issues which are in dispute
() Cause of Action
() Custody
() Parenting Time
() Alimony
() Child Support
() Equitable Distribution
() Counsel Fees
() Other
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CIS - PART A
CHILDREN INFORMATION
OLDEST CHILD
Oldest Child's First Name
Oldest Child's Last Name
Oldest Child's Birthdate
Oldest Child Resides with
2ND CHILD
2nd Child's First Name
2nd Child's Last Name
2nd Child's Birthdate
2nd Child Resides with
3RD CHILD
3rd Child's First Name
3rd Child's Last Name
3rd Child's Birthdate
3rd Child Resides with
4TH CHILD
4th Child's First Name
4th Child's Last Name
4th Child's Birthdate
4th Child Resides with
5TH CHILD
5th Child's First Name
5th Child's Last Name
5th Child's Birthdate
5th Child Resides with
6TH CHILD
6th Child's First Name
6th Child's Last Name
6th Child's Birthdate
6th Child Resides with
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CIS - PART A
CHILDREN FROM OTHER RELATIONSHIPS
OTHER RELATIONSHIP OLDEST CHILD
Other Relationship Child's First Name
Other Relationship Child's Last Name
Other Relationship Child's Birthdate
Other Relationship Child Resides with
OTHER RELATIONSHIP 2ND CHILD
Other Relationship Child's First Name
Other Relationship Child's Last Name
Other Relationship Child's Birthdate
Other Relationship Child Resides with
OTHER RELATIONSHIP 3RD CHILD
Other Relationship Child's First Name
Other Relationship Child's Last Name
Other Relationship Child's Birthdate
Other Relationship Child Resides with
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 Part A Part B Part C Part D Part E Part F
CIS - PART B
MISCELLANEOUS INFORMATION
Employer's Name
Street Address
City
State/Province
Zip/Postal Code
Employer's Name
Street Address
City
State/Province
Zip/Postal Code


CIS - PART B
INSURANCE 		*Press Tab Key to Move From Field to Field
Place the letter X in one or more boxes below to indicate your answer
Do you have Insurance obtained through Employment/Business? () Yes () No
Type of Insurance:    Medical () Yes () No
Dental () Yes () No
Prescription Drug () Yes () No
Life () Yes () No
Disability () Yes () No
Other
Is Insurance available through Employment/Business? () Yes () No
Explain


 Part A Part B Part C Part D Part E Part F
CIS - PART C
INCOME INFORMATION
Last Year's Income Yours Joint Spouse
Gross earned income last calendar year (specify year)
Unearned income (same year)
Describe
Total Income Taxes paid on above income (incl. Fed., State, F.I.C.A. and S.U.I.). If Joint Return, use middle line 


CIS - PART C
PRESENT EARNED INCOME INFORMATION
Current Pay Period (Select only one - Place an X in the box):
Weekly   Every Two Weeks   Twice per Month   Monthly
Date of Most Recent Pay Check (Format: mm/dd/yyyy): 
Three Most Recent Pay Checks Check #1 Check #2 Check #3
Gross Pay
Commissions and bonuses, etc., are:
(X applicable box) included
not included
not paid to you
DEDUCTIONS Enter the amount deducted.
Three Most Recent Pay Checks (X applicable) Check #1 Check #2 Check #3
Federal Taxes
State Taxes
FICA
SUI
Other


CIS - PART C
YOUR YEAR TO DATE INCOME
1. GROSS EARNED INCOME
2. TAX DEDUCTIONS: (Number of dependents )
a. Federal Income Taxes
b. N.J. Income Taxes
c. Other State Income Taxes
d. FICA
e. Medicare
f. S.U.I./S.D.I.
g. Estimated tax payments in excess of withholding actually made
h. Other (specify)
i. Other (specify)
4. OTHER DEDUCTIONS

if mandatory, check box
a. Hospitalization/Medical Insurance
b. Life Insurance
c. Union Dues
d. 401(k) Plans
e. Pension/Profit Sharing Plan
f. Other Plans (specify)
g. Charity
h. Wage Execution
g. Medical Reimbursement (flex fund)
h. Other (specify)


CIS - PART C
YOUR YEAR TO DATE GROSS UNEARNED INCOME
Source How Often Paid Year to Date Amount


CIS - PART C
ADDITIONAL INFORMATION
How Often Are you paid?
What is your annual salary?
Have you received any raises in the current year?
() Yes     () No
If yes, provide the date and the gross/net amount.
Do you receive bonuses, commissions, or other compensation, including distributions, taxable or non-taxable, in addition to your regular salary?
() Yes     () No
If yes, explain:
Did you receive bonuses, commissions, or other compensation, 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 and state the date(s) of receipt and set forth the gross and net amounts received:
Do you receive cash or distributions not otherwise listed?
() Yes     () No
If yes, explain:
Have you received income from overtime work during either the current or immediate past calendar year?
() Yes     () No
If yes, explain:
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:
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.
Have you received any 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:
List the names of the dependents you claim:
Are you paying or receiving any alimony?
() Yes     () No
If yes, how much and to whom paid or from whom received?
Are you paying or receiving any child support?
() Yes     () No
If yes, list names of the children, the amount paid or received for each child to whom paid or from whom received:
Is there a wage execution in connection with support?
() Yes     () No
If yes, explain:
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:
Explanation of income or other information:


 Part A Part B Part C Part D Part E Part F
CIS - PART D
EXPENSES
If Tenant: Joint marital life style family including (# ) children Current Life style Yours and (# ) children
Rent
Heat (if not furnished)
Electric & Gas (if not furnished)
Renter's Insurance
Parking (at apartment)
Other Charges (Itemize)
CIS - PART D
EXPENSES
If Homeowner: Joint Marital Life Style Family Current Life Style
Mortgage
Real Estate Taxes (unless included with mortgage payment)
Homeowners Insurance (unless included with mortgage payment)
Other Mortgages or Home Equity Loans (Specify)
Heat (unless electric or gas)
Electric & Gas
Water and Sewer
Garbage Removal
Snow Removal
Lawn Care
Maintenance Charges
Repairs
Other Charges (Itemize)
CIS - PART D
EXPENSES
Tenant or Homeowner: Joint Marital Life Style Current Life Style
Telephone
Mobile/Cellular Telephone
Service Contracts on Equipment
Cable TV
Plumber/Electrician
Equipment and furnishings
Internet Charges
Other (Itemize)


CIS - PART D
EXPENSES
Joint Marital Life Style Current Life Style
Auto Payment
Auto Insurance 
(number of vehicles )
Registration, License
Maintenance
Fuel and Oil
Commuting Expenses
Other Charges (Itemize)


CIS - PART D
EXPENSES
Joint Marital Life Style Current Life Style
Food at Home and household supplies 
Prescription Drugs
Non-prescription drugs, cosmetics, toiletries and sundries 
School Lunches 
Restaurants 
Clothing 
Dry Cleaning, Commercial Laundry 
Hair Care 
Domestic Help 
Medical (exclusive of psychiatric)* 
Eye Care* 
Psychiatric/psychological/counseling* 
Dental (exclusive of orthodontic)* 
Orthodontic* 
Medical Insurance (hospitalization, etc.)* 
Club Dues and Memberships 
Sports and Hobbies
Camps
Vacations
Children's Private School Costs
Parent's Educational Costs
Children's Lessons (dancing, music, sports, etc.)
Babysitting
Day Care Expenses
Entertainment
Alcohol and Tobacco
Newspapers and Periodicals
Gifts
Contributions
Payments to Non-Child Dependents
Prior Existing Support Obligations
(Specify)
Tax Reserve
Life Insurance
Savings/investment
Debt Service (exclusive of mortgage)
Parenting Time Expenses
Professional Expenses (other than this proceeding)
Other (specify)


 Part A Part B Part C Part D Part E Part F
CIS - PART E
BALANCE SHEET OF ALL FAMILY ASSETS AND LIABILITIES
STATEMENT OF ASSETS
Type Description Title to Property
(H,W,J)		 If you contend asset is fully or partially exempt from equitable distribution, state reason: Value
($)		 Date of Evaluation
Mo/Day/Yr


CIS - PART E
BALANCE SHEET OF ALL FAMILY ASSETS AND LIABILITIES
STATEMENT OF LIABILITIES
Type Description Respon-
sible
Party
(H,W,J)		 If you contend liability should not be considered in equitable distribution, state reason: Monthly
Payment		 Value
($)		 Date of Evaluation
Mo/Day/Yr
 Part A Part B Part C Part D Part E Part F
CIS - PART F
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.

 

REQUIRED ATTACHMENTS

1. A full and complete copy of your last federal and state income tax returns with all schedules and attachments. (Part C-1)

2. Your last calendar year's W-2 statements and 1099's, K-1 statements.

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. (Part C)

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. Affidavit of Insurance Coverage as required by Court Rule 5:4-2(f) (Part B-3)

7. List of all prior/pending family actions involving support, custody or Domestic Violence, with the Docket Number, County, State and the disposition reached. Attach copies of all existing Orders in effect. (Part B-5)

8. Attach details of each wage execution. (Part C-5)

9. Schedule of payments made for a spouse and/or children not reflected in Part D.

10. Any agreements between the parties. 

11. An Appendix IX Child Support Guideline Worksheet, as applicable, based upon available information.

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