Form OCSE388(E) "Income and Expenses Statement" - New York City, New York City

What Is Form OCSE388(E)?

This is a legal form that was released by the New York City Department of Social Services - a government authority operating within New York City. The form may be used strictly within New York City. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the New York City Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form OCSE388(E) by clicking the link below or browse more documents and templates provided by the New York City Department of Social Services.

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Download Form OCSE388(E) "Income and Expenses Statement" - New York City, New York City

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OCSE-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
Page 1 of 2
OCSE-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
Page 1 of 2
OCSE-388 (E) 11/2008
Rev. 05/2016
Assets
Savings Account:
Bank name: ___________________
Balance: $ _____________
Checking Account:
Bank name: ___________________
Balance: $ _____________
Automobile:
Year: __________ Make: ________
Value: $ _______________
Model: _______________________
House/Apt Owned:
Address: _______________________________________________
Market value: $__________________ Mortgage: $________________
Other assets:
Details: _____________________
Value: $ _______________
(other real estate, car,
boat, snowmobile, stocks,
Details: _____________________
Value: $ _______________
bonds, trailer, etc.)
(Include additional page of other assets, if needed.)
Expenses: The following expenses are ☐ monthly ☐ weekly.
Rent or mortgage:
$ _________
Health insurance:
$ _________
Utilities
Other insurance
Gas:
$ _________
Life:
$ _________
Phone/TV/internet:
$ _________
Auto:
$ _________
Electric:
$ _________
Home/Fire:
$ _________
Other: ______________
$ _________
Other: ______________
$ _________
Child care:
$ _________
Transportation
Auto payment:
$ _________
School tuition and expenses:
$ _________
Gasoline:
$ _________
Food:
$ _________
Public transportation:
$ _________
Clothing:
$ _________
Medical/Dental/Prescription:
$ _________
Other: ________________ $ _________
How many people are in your household?
Me + ________ others
Loans and Debt: Only list the loans and debts you are actually paying.
Owed to: ____________________________________ For: __________________________
Payment: $_____________ ☐ monthly ☐ weekly
Balance: $_________________
Owed to: ____________________________________ For: __________________________
Payment: $_____________ ☐ monthly ☐ weekly
Balance: $_________________
(Include additional page of other loans and debt, if needed.)
STOP! Take this document to a Notary Public BEFORE signing it.
I swear that the above information is true and correct as of
__________________.
(date)
______________________________________
Signature
Sworn to before me
on ________________________________
___________________________________
Notary Public / (Deputy) Clerk of the Court
Financial Disclosure Affidavit – Short version
Page 2 of 2
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