Mediation Form Part III Employment, Income and Equitable Distribution

Form Part III
EMPLOYMENT, MAINTENANCE, HEALTH INSURANCE, ASSETS, DEBTS, AND EQUITABLE DISTRIBUTION (Continued)

Security


Today's Date:

Email of person completing this form (required)


EMPLOYMENT AND MAINTENANCE

Husband's Employment

Husband presently employed.

If employed Husband's Occupation is
If employed Husband's Employer is

Husband presently able to be self-supporting and imminently in danger of becoming a public charge.

Wife's Employment

Wife presently employed.

If employed Wife's Occupation is
If employed Wife's Employer is

Wife presently able to be self-supporting and 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:

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 to for a period of weeks.

The basis for this agreement on maintenance is:

https://www.nycourts.gov/divorce/MaintenanceChildSupportTools.shtml

HEALTH INSURANCE

Husband's Health Insurance





Wife's Health Insurance





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 bank account(s).

The parties have no bank accounts in their names or the joint names of the parties.

Bank Account 1

 Account Type: Account Owner: Account Balance:Disposition of Account:

Bank Account 1

 Account Type: Account Owner: Account Balance:Disposition of Account:

Bank Account 2

 Account Type: Account Owner: Account Balance:Disposition of Account:

Bank Account 1

 Account Type: Account Owner: Account Balance:Disposition of Account:

Bank Account 2

 Account Type: Account Owner: Account Balance:Disposition of Account:

Bank Account 3

 Account Type: Account Owner: Account Balance:Disposition of Account:

Bank Account 1

 Account Type: Account Owner: Account Balance:Disposition of Account:

Bank Account 2

 Account Type: Account Owner: Account Balance:Disposition of Account:

Bank Account 3

 Account Type: Account Owner: Account Balance:Disposition of Account:

Bank Account 4

 Account Type: Account Owner: Account Balance:Disposition of Account:

REAL ESTATE

The parties agree that they own 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
The Real Estate acquired by the parties during their marraiage.
For purposes of this agreement, the parties agree that this Real Estate 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
The Real Estate acquired by the parties during their marraiage.
For purposes of this agreement, the parties agree that this Real Estate 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
The Real Estate acquired by the parties during their marraiage.
For purposes of this agreement, the parties agree that this Real Estate 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
The Real Estate acquired by the parties during their marraiage.
For purposes of this agreement, the parties agree that this Real Estate 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
The Real Estate acquired by the parties during their marraiage.
For purposes of this agreement, the parties agree that this Real Estate 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
The Real Estate acquired by the parties during their marraiage.
For purposes of this agreement, the parties agree that this Real Estate 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
The Real Estate acquired by the parties during their marraiage.
For purposes of this agreement, the parties agree that this Real Estate 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
The Real Estate acquired by the parties during their marraiage.
For purposes of this agreement, the parties agree that this Real Estate 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
The Real Estate acquired by the parties during their marraiage.
For purposes of this agreement, the parties agree that this Real Estate 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
The Real Estate acquired by the parties during their marraiage.
For purposes of this agreement, the parties agree that this Real Estate 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 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
The Vehicle acquired by the parties during their marraiage.
For purposes of this agreement, the parties agree that this Vehicle 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:

Vehicle 1

 The parties own a motor vehicle known to them as a: This Vehicle is in the
The Vehicle acquired by the parties during their marraiage.
For purposes of this agreement, the parties agree that this Vehicle 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:

Vehicle 2

 The parties own a motor vehicle known to them as a: This Vehicle is in the
The Vehicle acquired by the parties during their marraiage.
For purposes of this agreement, the parties agree that this Vehicle 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:

Vehicle 1

 The parties own a motor vehicle known to them as a: This Vehicle is in the
The Vehicle acquired by the parties during their marraiage.
For purposes of this agreement, the parties agree that this Vehicle 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:

Vehicle 2

 The parties own a motor vehicle known to them as a: This Vehicle is in the
The Vehicle acquired by the parties during their marraiage.
For purposes of this agreement, the parties agree that this Vehicle 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:

Vehicle 3

 The parties own a motor vehicle known to them as a: This Vehicle is in the
The Vehicle acquired by the parties during their marraiage.
For purposes of this agreement, the parties agree that this Vehicle 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:

Vehicle 1

 The parties own a motor vehicle known to them as a: This Vehicle is in the
The Vehicle acquired by the parties during their marraiage.
For purposes of this agreement, the parties agree that this Vehicle 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:

Vehicle 2

 The parties own a motor vehicle known to them as a: This Vehicle is in the
The Vehicle acquired by the parties during their marraiage.
For purposes of this agreement, the parties agree that this Vehicle 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:

Vehicle 3

 The parties own a motor vehicle known to them as a: This Vehicle is in the
The Vehicle acquired by the parties during their marraiage.
For purposes of this agreement, the parties agree that this Vehicle 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:

Vehicle 4

 The parties own a motor vehicle known to them as a: This Vehicle is in the
The Vehicle acquired by the parties during their marraiage.
For purposes of this agreement, the parties agree that this Vehicle 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:

RETIREMENT ACCOUNT(S)

With respect to their retirement accounts if any the parties have agreed:

SUBSEQUENT TAX RETURN(S)

With respect to subsequently filed or pending tax returns, if any, the parties have agreed:

MARITAL AND NONMARITAL DEBT(S)

With respect to subsequently filed or pending tax returns, if any, the parties have agreed: