Mediation Form Part III Employment, Income and Equitable Distribution Form Part III EMPLOYMENT, MAINTENANCE, HEALTH INSURANCE, ASSETS, DEBTS, AND EQUITABLE DISTRIBUTION (Continued) Security Unique Pin (Required) Today's Date: Email of person completing this form (required) Wife's Last Name (required) Husband's Last Name (required) EMPLOYMENT AND MAINTENANCE Husband's Employment Husband isis not presently employed. If employed Husband's Occupation is If employed Husband's Employer is Husband isis not presently able to be self-supporting and isis not imminently in danger of becoming a public charge. Wife's Employment Wife isis not presently employed. If employed Wife's Occupation is If employed Wife's Employer is Wife isis not presently able to be self-supporting and isis not imminently in danger of becoming a public charge. Income In the last filed income tax return the parties claimed combined gross joint income for federal tax purposes of: Husband's Yearly Employment Income is presently: Wife's Yearly Employment Income is presently: In addition, the parties had rental or nonrecurring income from the following source: None The Parties have each waived their right to see maintenance from each other. YesNo Based on the foregoing the parties have agreed that maintenance of shall be paid by Not ApplicableHusbandWife to Not ApplicableHusbandWife for a period of weeks. The basis for this agreement on maintenance is: The parties have agreed to the terms of maintenance that are contained in this agreement based upon all of the other concessions and trade-offs they have made in it. https://www.nycourts.gov/divorce/MaintenanceChildSupportTools.shtml HEALTH INSURANCE Husband's Health Insurance Husband's group plan name: Husband's plan address: Husband's identification number: Husband's plan administrator: Husband's type of coverage: Wife's Health Insurance Wife's group plan name: Wife's plan address: Wife's identification number: Wife's plan administrator: Wife's type of coverage: Health Insurance Selection MEDICAL INSURANCE - The parties have agreed that once a judgment of divorce is filed, the Husband shall continue to provide medical insurance for the benefit of the minor child(ren) for so long as permitted by the parties current insurance carrier at similar costs to what was paid for such insurance while the parties were married and that the Wife shall provide for her own health insurance needs after the parties are divorced.MEDICAL INSURANCE - The parties have agreed that once a judgment of divorce is filed, the Wife shall continue to provide medical insurance for the benefit of the minor child(ren) for so long as permitted by the parties current insurance carrier at similar costs to what was paid for such insurance while the parties were married and that the Husband shall provide for his own health insurance needs after the parties are divorced.MEDICAL INSURANCE - The parties have agreed that once a judgment of divorce is filed that they each shall be responsible for there own health insurance and care expenses. BANK ACCOUNTS The parties agree that they have 01234 bank account(s). The parties have no bank accounts in their names or the joint names of the parties. Bank Account 1 Account Type:CheckingSavingsMoney Market Account Owner:Joint Names of the PartiesHusbandWife Account Balance:Disposition of Account:HusbandWifeNeither Party, and is to be divided equally and closed Bank Account 1 Account Type:CheckingSavingsMoney Market Account Owner:Joint Names of the PartiesHusbandWife Account Balance:Disposition of Account:HusbandWifeNeither Party, and is to be divided equally and closed Bank Account 2 Account Type:CheckingSavingsMoney Market Account Owner:Joint Names of the PartiesHusbandWife Account Balance:Disposition of Account:HusbandWifeNeither Party, and is to be divided equally and closed Bank Account 1 Account Type:CheckingSavingsMoney Market Account Owner:Joint Names of the PartiesHusbandWife Account Balance:Disposition of Account:HusbandWifeNeither Party, and is to be divided equally and closed Bank Account 2 Account Type:CheckingSavingsMoney Market Account Owner:Joint Names of the PartiesHusbandWife Account Balance:Disposition of Account:HusbandWifeNeither Party, and is to be divided equally and closed Bank Account 3 Account Type:CheckingSavingsMoney Market Account Owner:Joint Names of the PartiesHusbandWife Account Balance:Disposition of Account:HusbandWifeNeither Party, and is to be divided equally and closed Bank Account 1 Account Type:CheckingSavingsMoney Market Account Owner:Joint Names of the PartiesHusbandWife Account Balance:Disposition of Account:HusbandWifeNeither Party, and is to be divided equally and closed Bank Account 2 Account Type:CheckingSavingsMoney Market Account Owner:Joint Names of the PartiesHusbandWife Account Balance:Disposition of Account:HusbandWifeNeither Party, and is to be divided equally and closed Bank Account 3 Account Type:CheckingSavingsMoney Market Account Owner:Joint Names of the PartiesHusbandWife Account Balance:Disposition of Account:HusbandWifeNeither Party, and is to be divided equally and closed Bank Account 4 Account Type:CheckingSavingsMoney Market Account Owner:Joint Names of the PartiesHusbandWife Account Balance:Disposition of Account:HusbandWifeNeither Party, and is to be divided equally and closed REAL ESTATE The parties agree that they own 01234 parcels of Real Estate. The parties do not own Real Estate. Real Estate 1 The parties own Real Estate located at: This property is in the Joint Names of the Parties.Husband's Name.Wife's Name. The Real Estate waswas not acquired by the parties during their marraiage. For purposes of this agreement, the parties agree that this Real Estate isis not considered marital property. The properties current fair market value is: The property is subject to a mortgage or other debt in the amount of: The parties have agreed to the following with respect to this property: Real Estate 1 The parties own Real Estate located at: This property is in the Joint Names of the Parties.Husband's Name.Wife's Name. The Real Estate waswas not acquired by the parties during their marraiage. For purposes of this agreement, the parties agree that this Real Estate isis not considered marital property. The properties current fair market value is: The property is subject to a mortgage or other debt in the amount of: The parties have agreed to the following with respect to this property: Real Estate 2 The parties own Real Estate located at: This property is in the Joint Names of the Parties.Husband's Name.Wife's Name. The Real Estate waswas not acquired by the parties during their marraiage. For purposes of this agreement, the parties agree that this Real Estate isis not considered marital property. The properties current fair market value is: The property is subject to a mortgage or other debt in the amount of: The parties have agreed to the following with respect to this property: Real Estate 1 The parties own Real Estate located at: This property is in the Joint Names of the Parties.Husband's Name.Wife's Name. The Real Estate waswas not acquired by the parties during their marraiage. For purposes of this agreement, the parties agree that this Real Estate isis not considered marital property. The properties current fair market value is: The property is subject to a mortgage or other debt in the amount of: The parties have agreed to the following with respect to this property: Real Estate 2 The parties own Real Estate located at: This property is in the Joint Names of the Parties.Husband's Name.Wife's Name. The Real Estate waswas not acquired by the parties during their marraiage. For purposes of this agreement, the parties agree that this Real Estate isis not considered marital property. The properties current fair market value is: The property is subject to a mortgage or other debt in the amount of: The parties have agreed to the following with respect to this property: Real Estate 3 The parties own Real Estate located at: This property is in the Joint Names of the Parties.Husband's Name.Wife's Name. The Real Estate waswas not acquired by the parties during their marraiage. For purposes of this agreement, the parties agree that this Real Estate isis not considered marital property. The properties current fair market value is: The property is subject to a mortgage or other debt in the amount of: The parties have agreed to the following with respect to this property: Real Estate 1 The parties own Real Estate located at: This property is in the Joint Names of the Parties.Husband's Name.Wife's Name. The Real Estate waswas not acquired by the parties during their marraiage. For purposes of this agreement, the parties agree that this Real Estate isis not considered marital property. The properties current fair market value is: The property is subject to a mortgage or other debt in the amount of: The parties have agreed to the following with respect to this property: Real Estate 2 The parties own Real Estate located at: This property is in the Joint Names of the Parties.Husband's Name.Wife's Name. The Real Estate waswas not acquired by the parties during their marraiage. For purposes of this agreement, the parties agree that this Real Estate isis not considered marital property. The properties current fair market value is: The property is subject to a mortgage or other debt in the amount of: The parties have agreed to the following with respect to this property: Real Estate 3 The parties own Real Estate located at: This property is in the Joint Names of the Parties.Husband's Name.Wife's Name. The Real Estate waswas not acquired by the parties during their marraiage. For purposes of this agreement, the parties agree that this Real Estate isis not considered marital property. The properties current fair market value is: The property is subject to a mortgage or other debt in the amount of: The parties have agreed to the following with respect to this property: Real Estate 4 The parties own Real Estate located at: This property is in the Joint Names of the Parties.Husband's Name.Wife's Name. The Real Estate waswas not acquired by the parties during their marraiage. For purposes of this agreement, the parties agree that this Real Estate isis not considered marital property. The properties current fair market value is: The property is subject to a mortgage or other debt in the amount of: The parties have agreed to the following with respect to this property: MOTOR VEHICLE(S) The parties agree that they own 01234 motor vehicle(s). For purposes of this paragraph the word "motor vehicle" shall refer to Automobiles, Trucks, Trailers, Boats, Motorcycles and Recreational Vehicles. The parties do not own any Motor Vehicles. Vehicle 1 The parties own a motor vehicle known to them as a: This Vehicle is in the Joint Names of the Parties.Husband's Name.Wife's Name. The Vehicle waswas not acquired by the parties during their marraiage. For purposes of this agreement, the parties agree that this Vehicle isis not considered marital property. The vehicles current fair market value is: The Vehicle is subject to a debt in the amount of: The parties have agreed to the following with respect to this Vehicle: The parties agree that this property shall be deemed the Husband's sole and separate property and that the Husband shall be responsible for all costs associated with said ownership of said vehicle including any debt that is associated with it. OR The parties agree that this property shall be deemed the Wife's sole and separate property and that the Wife shall be responsible for all costs associated with said ownership of said vehicle including any debt that is associated with it. Vehicle 1 The parties own a motor vehicle known to them as a: This Vehicle is in the Joint Names of the Parties.Husband's Name.Wife's Name. The Vehicle waswas not acquired by the parties during their marraiage. For purposes of this agreement, the parties agree that this Vehicle isis not considered marital property. The vehicles current fair market value is: The Vehicle is subject to a debt in the amount of: The parties have agreed to the following with respect to this Vehicle: The parties agree that this property shall be deemed the Husband's sole and separate property and that the Husband shall be responsible for all costs associated with said ownership of said vehicle including any debt that is associated with it. OR The parties agree that this property shall be deemed the Wife's sole and separate property and that the Wife shall be responsible for all costs associated with said ownership of said vehicle including any debt that is associated with it. Vehicle 2 The parties own a motor vehicle known to them as a: This Vehicle is in the Joint Names of the Parties.Husband's Name.Wife's Name. The Vehicle waswas not acquired by the parties during their marraiage. For purposes of this agreement, the parties agree that this Vehicle isis not considered marital property. The vehicles current fair market value is: The Vehicle is subject to a debt in the amount of: The parties have agreed to the following with respect to this Vehicle: The parties agree that this property shall be deemed the Husband's sole and separate property and that the Husband shall be responsible for all costs associated with said ownership of said vehicle including any debt that is associated with it. OR The parties agree that this property shall be deemed the Wife's sole and separate property and that the Wife shall be responsible for all costs associated with said ownership of said vehicle including any debt that is associated with it. Vehicle 1 The parties own a motor vehicle known to them as a: This Vehicle is in the Joint Names of the Parties.Husband's Name.Wife's Name. The Vehicle waswas not acquired by the parties during their marraiage. For purposes of this agreement, the parties agree that this Vehicle isis not considered marital property. The vehicles current fair market value is: The Vehicle is subject to a debt in the amount of: The parties have agreed to the following with respect to this Vehicle: The parties agree that this property shall be deemed the Husband's sole and separate property and that the Husband shall be responsible for all costs associated with said ownership of said vehicle including any debt that is associated with it. OR The parties agree that this property shall be deemed the Wife's sole and separate property and that the Wife shall be responsible for all costs associated with said ownership of said vehicle including any debt that is associated with it. Vehicle 2 The parties own a motor vehicle known to them as a: This Vehicle is in the Joint Names of the Parties.Husband's Name.Wife's Name. The Vehicle waswas not acquired by the parties during their marraiage. For purposes of this agreement, the parties agree that this Vehicle isis not considered marital property. The vehicles current fair market value is: The Vehicle is subject to a debt in the amount of: The parties have agreed to the following with respect to this Vehicle: The parties agree that this property shall be deemed the Husband's sole and separate property and that the Husband shall be responsible for all costs associated with said ownership of said vehicle including any debt that is associated with it. OR The parties agree that this property shall be deemed the Wife's sole and separate property and that the Wife shall be responsible for all costs associated with said ownership of said vehicle including any debt that is associated with it. Vehicle 3 The parties own a motor vehicle known to them as a: This Vehicle is in the Joint Names of the Parties.Husband's Name.Wife's Name. The Vehicle waswas not acquired by the parties during their marraiage. For purposes of this agreement, the parties agree that this Vehicle isis not considered marital property. The vehicles current fair market value is: The Vehicle is subject to a debt in the amount of: The parties have agreed to the following with respect to this Vehicle: The parties agree that this property shall be deemed the Husband's sole and separate property and that the Husband shall be responsible for all costs associated with said ownership of said vehicle including any debt that is associated with it. OR The parties agree that this property shall be deemed the Wife's sole and separate property and that the Wife shall be responsible for all costs associated with said ownership of said vehicle including any debt that is associated with it. Vehicle 1 The parties own a motor vehicle known to them as a: This Vehicle is in the Joint Names of the Parties.Husband's Name.Wife's Name. The Vehicle waswas not acquired by the parties during their marraiage. For purposes of this agreement, the parties agree that this Vehicle isis not considered marital property. The vehicles current fair market value is: The Vehicle is subject to a debt in the amount of: The parties have agreed to the following with respect to this Vehicle: The parties agree that this property shall be deemed the Husband's sole and separate property and that the Husband shall be responsible for all costs associated with said ownership of said vehicle including any debt that is associated with it. OR The parties agree that this property shall be deemed the Wife's sole and separate property and that the Wife shall be responsible for all costs associated with said ownership of said vehicle including any debt that is associated with it. Vehicle 2 The parties own a motor vehicle known to them as a: This Vehicle is in the Joint Names of the Parties.Husband's Name.Wife's Name. The Vehicle waswas not acquired by the parties during their marraiage. For purposes of this agreement, the parties agree that this Vehicle isis not considered marital property. The vehicles current fair market value is: The Vehicle is subject to a debt in the amount of: The parties have agreed to the following with respect to this Vehicle: The parties agree that this property shall be deemed the Husband's sole and separate property and that the Husband shall be responsible for all costs associated with said ownership of said vehicle including any debt that is associated with it. OR The parties agree that this property shall be deemed the Wife's sole and separate property and that the Wife shall be responsible for all costs associated with said ownership of said vehicle including any debt that is associated with it. Vehicle 3 The parties own a motor vehicle known to them as a: This Vehicle is in the Joint Names of the Parties.Husband's Name.Wife's Name. The Vehicle waswas not acquired by the parties during their marraiage. For purposes of this agreement, the parties agree that this Vehicle isis not considered marital property. The vehicles current fair market value is: The Vehicle is subject to a debt in the amount of: The parties have agreed to the following with respect to this Vehicle: The parties agree that this property shall be deemed the Husband's sole and separate property and that the Husband shall be responsible for all costs associated with said ownership of said vehicle including any debt that is associated with it. OR The parties agree that this property shall be deemed the Wife's sole and separate property and that the Wife shall be responsible for all costs associated with said ownership of said vehicle including any debt that is associated with it. Vehicle 4 The parties own a motor vehicle known to them as a: This Vehicle is in the Joint Names of the Parties.Husband's Name.Wife's Name. The Vehicle waswas not acquired by the parties during their marraiage. For purposes of this agreement, the parties agree that this Vehicle isis not considered marital property. The vehicles current fair market value is: The Vehicle is subject to a debt in the amount of: The parties have agreed to the following with respect to this Vehicle: The parties agree that this property shall be deemed the Husband's sole and separate property and that the Husband shall be responsible for all costs associated with said ownership of said vehicle including any debt that is associated with it. OR The parties agree that this property shall be deemed the Wife's sole and separate property and that the Wife shall be responsible for all costs associated with said ownership of said vehicle including any debt that is associated with it. RETIREMENT ACCOUNT(S) With respect to their retirement accounts if any the parties have agreed: The parties have disclosed information to each other and they have also made an independent inquiry about their respective retirement account(s). The parties have agreed to the following division of their retirement accounts. If the parties’ agreement requires the division of a retirement account by a Domestic Relations Order or a Qualified Domestic relations order, then the parties agree that the costs and attorney fees to obtain those necessary orders shall be equally divided between the parties. The parties have agreed to the following: The parties have agreed that they each shall retain any retirement accounts in their respective names as their sole and separate property. SUBSEQUENT TAX RETURN(S) With respect to subsequently filed or pending tax returns, if any, the parties have agreed: The parties agree that they shall file their next Federal and State income tax return Separately and divide any refund and or amount owed according to the following: Each party shall retain their own income tax return refund or liability as their own sole and separate property or responsibility. MARITAL AND NONMARITAL DEBT(S) With respect to subsequently filed or pending tax returns, if any, the parties have agreed: Other than specifically agreed elsewhere in this agreement the parties agree that they shall pay the debts that are in their respective names. In addition, the parties have agreed to the following with respect to certain specific debts: The Capital of New York? 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