I, ___________________ W/o/D/O_________________________________________________, Aged about _________________years, Resident of ______________________________, do hereby solemnly affirm and declare as under:

PART - I

PERSONAL INFORMATION RELATING TO THE DEPONENT

Sl. No.	Description	Particulars
1.	Name
2.	Age
3.	Date of marriage
4.	Date of separation
5.	Educational qualifications
6.	Professional qualifications
7.	Occupation
8.	Monthly income (Give details in Part IV)
9.	Monthly expenditure (Give details in Part V)
10.	Whether you are assessed to Income Tax?
11.	Whether you are assessed to Wealth Tax?
12.	Whether you have sufficient income to support yourself?
13.	If not, whether you have claimed maintenance from your spouse? If so, how much?
14.	Whether you are staying in matrimonial home?
15.	If not staying in the matrimonial home, relationship and income of the person with whom staying.
16.	Members of the family:
	(a) Dependent
	(b) Independent
17.	Whether your spouse has claimed maintenance from you? If so, how much?
18.	Whether you have voluntarily paid or willing to pay maintenance to your spouse? If so, how much?
19.	Whether you are willing to pay litigation expenses to your spouse? If so, how much?
20.	Particulars of pending litigation between the parties
21.	Whether any maintenance order has been passed by any Court? If so, give particulars and attach copies of the order?
22.	Whether the maintenance is being paid in terms of the aforesaid order? If so, file the statement of maintenance paid upto date
23.	E-mail address
24.	Name of your counsel and his/her e-mail address
25.	Expenses incurred on this litigation
26.	Particulars of the bank account with name and address of the bank for the purpose of payment from or receipt of maintenance, as the case may be

PART – II

RELEVANT INFORMATION RELATING TO THE SPOUSE

Sl. No	Description	Particulars
1.	Educational and professional qualifications of your spouse
2.	Whether your spouse is earning? If so, give particulars of the occupation and income of your spouse.
3.	Whether your spouse is staying in the Matrimonial Home. If not, whether she is staying in his/her own accommodation or in a rented accommodation? If staying in a rented accommodation, what is the rent being paid by him/her?
4.	Particulars of the assets and liabilities of your spouse
5.	Do you have any documents relating to the income, assets and expenditure of your spouse? If so, give the particulars and attach copies thereof?

PART – III

RELEVANT INFORMATION RELATING TO THE CHILDREN

Sl. No	Description	Particulars
1.	Children from the marriage with their name and age
2.	Who has the custody of the Children?
3.	Expenditure on the education of the Children (Give details in Clause 7)
4.	Who is bearing the expenditure of Children's education
5.	How much expenditure has been incurred on the children's maintenance and children's education from the date of separation till now?
6.	If the children are in custody of your spouse, whether you have voluntarily paid or willing to pay the expenses for the children's maintenance and education? If so, how much?
7.	Details of Expenditure on Education	Amount in (Rs.)
	(i) School fees (ii) Crech/Day Care/After school care (iii) Books/Stationery (iv) Private Tuitions (v) Sports (vi) Outings/summer camps / vacations (vii) Entertainment (viii)Others

PART-IV

STATEMENT OF INCOME

Sl. No.	Description	Particulars
1.	In case of salaried persons:
	(i) Designation
(ii) Name and address of the employer
(iii) Date of employment
(iv) Gross Income including the salary, D.A., commissions/incentives, bonus, perks etc.
(v) Perquisites and other benefits provided by the employer including accommodation, cars/other automotive, sweeper, gardener, watchman or personal attendant, gas, electricity, water, interest free or concessional loans, holiday expenses, free or concessional travel, free meals, free education, gifts, vouchers, etc. credit card expenses, club expenses, use of movable assets by employees, transfer of assets to employees, value of any other benefit/amenity/service/ privilege and the value of such perquisites and benefits
(vi) Deductions from the gross income
(vii) Income tax paid
(viii) Net income
(ix) Value of stock option benefits if provided by the employer
(x) Pension and retirement benefits payable at the time of retirement
2.	In case of Self Employed Persons
	(i) Nature of business/profession (ii) Whether the business/profession is carried on as an individual, sole proprietorship concern, partnership concern, company or association of persons, HUF, joint family business or any other form. Give particulars of your share in the business/ profession. In case of partnership, specify the share in the profit/losses of the partnership (iii) Number of employees (iv) Annual turnover/gross receipts (v) Gross Profit (vi) Income Tax (vii) Net Income (viii) Details and value of benefits in kind, perks or other remuneration received from the business e.g. provision of car, payment of accommodation etc (ix) Amount of regular monthly withdrawal or drawings from the business (x) Current value of your business interest(s) (xi) Current value of your business assets (xii) List of directorships held, sitting fees, commission or any other remuneration (xiii)Net worth of the company in which you are Director along with the number of shares held in the Company
3.	Income from Other Sources
	(i) Agricultural Income (ii) Rent (iii) Interest on bank deposits and FDRs (iv) Interest on investments including deposits, NSC, IVP, KVP, Post Office schemes, PPF, loans etc. (v) Dividends (vi) Income from machinery, plant or furniture let on hire. (vii) Gifts (viii) Profit on sale of movable/ immovable assets
4.	Any Other Income Not covered above
	TOTAL INCOME (Give monthly Income)

PART V

STATEMENT OF EXPENDITURE

(ESTIMATED EXPENDITURE IN CASE THE COMPLAINANT SHIFT TO ANOTHER HOUSE)

Sl. No.	Description	Particulars
1.	Housing	Monthly rent
Mortgage payment(s)
Repairs & Maintenance
Property tax
2.	House Hold Expenditure	Groceries/Food/Personal care/clothing
Water
Electricity
Gas
Telephone
TV Cable/Set-top Box charges & Internet services
Maintenance, replacement and repair of household items, appliances and kitchenware items.
Telephone
Domestic full time/part time servant(s)
Others (specify)
3.	Transport	(i) Car/Scooter
		(a) Driver(s)
(b) Fuel
(c) Repair/Maintenance
(d) Insurance
(e) Loan repayment
(ii) Public Transport
(a) Bus
(b) Taxi
(c) Metro
(d) Auto
4.	Medical Expenditure	Doctor
		Medication
		Hospital
		Other medical expenditure
		Others (specify)
5.	Insurance	Life
		Annuity
		Householders
6.	Entertainment and Recreation	Club
		Health Club
		Gym
7.	Holiday and Vacations
8.	Gifts
9.	Pocket Money/ Allowances
10.	Legal /Litigation Expenses
11.	Discharge of Liabilities	Credit Card(s) Payment
		Hire Purchase/ Lease
		Repayment of Loans
		House Loan
		Car Loan
		Personal Loan
		Business Loan
		Any Other Loan
		Name of Lenders
		Mode of Repayment
		Instalment Amount
		Other Personal Liabilities
12.	Miscellaneous	News Paper, Magazines, Books
		Religious Contributions / Charities
		Others (Specify)
13.	Other Expenditure (Not Specified above)
TOTAL EXPENDITURE (Give Monthly Expenditure)

PART - VI

STATEMENT OF ASSETS

S. No	Assets	Particulars	Estimated Market Value
1.	Real Estate Including land, built up properties, lease hold properties, agricultural land and investment in real estate such as booking of plots, flats and other immovable properties in your name or joint names. List any interest in properties, including lease hold interest and mortgages, whether or not you are registered as owner. Provide legal descriptions and indicate estimated market value of your interest without deducting encumbrances or costs of disposition.) (Record encumbrances under debts.)
	Financial Asset	Account No. & Bank Name	Current Balance
	(i) Details of all bank accounts including Current and Savings Accounts in your name, or joint name and balance in the said account (ii) Cash in hand
3.	Investments	Particulars	Current Value
	Details of all investments you hold or, in which you have interest and their current value: (i) FDRs, NSC, IVP, KVP, Post Office schemes, PPF etc. (ii) Deposits with Government and Non Government entities (iii) Stocks, shares, debentures, bonds, units and mutual funds, etc. (iv) Life and endowment policies and surrender value (v) Loan given to friends, relatives and others (vi) Other investments not covered by above items
4.	Pension and Registered Retirement Saving Plan	Particulars	Maturity Amount
	Indicate name of institution where accounts are held, name and address of pension plan and pension details
5.	Corporate / Business Interest	Particulars	Current Value
	List any interest you hold, directly or indirectly, in any corporation, unincorporated business, partnership, trust, joint venture and Association of Persons, Society etc.
6.	Movable Assets
(i) Motor Vehicles (List cars, motorcycles, scooters etc. along with their brand and registration number) (ii) Livestock (iii) Mobile phone(s) (iv) Computer/Laptop (v) Other electronic gadgets including I-pad etc. (vi) TV, Fridge, Air Conditioner, etc. (vii) Other household appliances (viii) Quantity of gold, silver and diamond jewellery (ix) Quantity of Silver Utensils
7.	Intangible Properties including patents, trademark, copyright design and goodwill and their value
8.	About disposal of Properties	Particulars	Sales Consideration Received
	Particulars of properties (movable as well as immovable) sold/agreed to be sold between the date of marriage or one year from separation whichever is later upto the date of filing this affidavit and the sale consideration received from the purchaser
9.	Others	Particulars	Estimated Current Value
	List anything else of value that you own, including precious metals, collections, works of art, jewellery or household items of high value. Include location of any safety deposit lockers

PART - VII

JOINT PROPERTIES OF THE PARTIES

S. No.	Description	Particulars
1.	Properties presented at or about the time of marriage, which belong jointly to both the husband and wife. Give the status of their possession
2.	Other joint properties of the parties. Give the status of their possession

PART – VIII

STATEMENT OF LIABILITIES

S. No.	Description	Particulars of Debt	Current Value
1.	Secured debt(s) List all mortgages, loans, and any other debts secured against an asset
2.	Unsecured Debt(s) List all bank loans, personal loans, credits, overdrafts, credit cards and any other debts
3.	Other List any other debts, including obligations that are relevant to a claim

PART – IX

GENERAL INFORMATION RELATING TO THE STATUS, STANDARD OF LIVING AND LIFESTYLE

S. No	Description	Particulars
1.	Residential address
2.	Area of residential accommodation (in sq. feet)
3.	Who is the owner of the residential accommodation? In case of rented accommodation, specify the monthly rent
4.	Name of school(s) where the child or children are studying
5.	Number of part-time/full time domestic servants and their wages
6.	Average monthly withdrawal from bank(s)
7.	Mode of travel in city/outside city
8.	Membership of clubs/health clubs/gyms, societies and other associations. Specify the membership fee and subscription
9.	Particulars of credit/debit cards, its limit and usage
10.	Particulars of frequent flier cards
11.	Frequency of foreign travel, business as well as personal
12.	Category of hotels ordinarily used for stay, official as well as personal
13.	Category of hospitals opted for medical treatment including type of rooms
14.	Brand of vehicle, mobile and wrist watch
15.	Expenditure ordinarily incurred on family functions including birthday of the children
16.	Expenditure ordinarily incurred on festivals
17.	Expenditure incurred on marriage of family members
18.	Status of the party/family:
	- High - Upper Middle - Middle - Lower Middle - Low - Below poverty line

PART X

DOCUMENTS RELATING TO ASSETS, INCOME AND EXPENDITURE OF THE DEPONENT

PART A

DOCUMENTS RELATING TO PERSONAL INFORMATION

	S. No	Description
1.	Aadhar Card
2.	PAN Card
3.	Passport

PART B

DOCUMENTS RELATING TO INCOME, ASSETS AND LIABILITIES

S. No	Description	Please Tick
		Attached	Not applicable	To follow
4.	Statement of Account of all bank accounts including current and savings accounts for last 3 years
5.	Income Tax Return(s) along with Statement of Income and Annexures for last 3 years
6.	Wealth Tax return(s) with statement of assets/liabilities for the last 3 years
7.	In case of Salaried Persons (i) Appointment Letter (ii) Salary slip (iii) Forms 16, 16A & 12BA (iv) Cost to Company Certificate and CIBIL Certificate, wherever applicable (v) Copies of TDS certificates
8.	In case of self-employed persons (i) Balance Sheet and Profit & Loss Account (ii) Balance Sheet and Profit & Loss Account of the proprietorship firm, if the business is carried on in the name of a sole proprietorship concern (iii) Balance Sheet and Profit & Loss Account of the partnership firm, if the deponent is a partner in a firm along with the Schedule showing the distribution of partners' remuneration and share of profits/losses of the partnership firm and the copy of the partnership deed (iv) Balance Sheet and Profit & Loss Account of the Company in which the deponent is a Director (v) Balance Sheet and Profit & Loss Account of the Association of Persons, HUF, Joint Family business or trust in which the deponent has share (vi) Copies of TDS certificates
9.	In case of Income from other sources:
	(i)Lease Deed(s)/Rent Agreement(s) /Licence Agreement(s) in respect of the rental income (ii) Interest Certificate in respect of the interest income on deposits and investments (iii) Dividend Certificates in respect of dividend income (iv) Sale Deed(s)/ transfer documents in respect of the profit on sale of property/ properties
10.	Other relevant documents relating to Income/Assets
11.	Other relevant documents relating to liabilities

PART C

DOCUMENTS RELATING TO EXPENDITURE

12.

(i) Documents relating to the expenditure on education of children including tuition fees

(ii) Rent and maintenance receipts

(iii) Electricity, water, security and gas bills

(iv) Documents relating to the salary paid to the employees including servant(s)

(v) Documents relating to expenditure on conveyance

(vi) Debit and Credit Card statements

(vii) Frequent Flier's Card statements

(viii) Mobile and landline phone bills

(ix) Internet and TV cable/ Set - Top Box bills

(x) Documents relating to the re- payment of the loans

(xi) PPF, EPF and other superannuation fund receipts

(xii) Receipts of premium of insurance policies

(xiii) Receipts of payments in respect of mutual funds

(xiv) Documents relating to payment of interest on bank and other loans

(xv) Documents relating to the payment of taxes, including Income Tax, Wealth Tax and Property Tax

(xvi) Other relevant documents relating to Expenditure

Declaration:

1. I declare that I have made full and accurate voluntary disclosure of my income, expenditure, assets and liabilities from all sources. I further declare that I have no assets, income, expenditure and liabilities other than set out in this affidavit.

2. I undertake to inform this Court immediately upon any material change in my employment, assets, income, expenses or any other information included in this affidavit.

3. I understand that any false statement in this affidavit may constitute an offence under Section 199 read with Sections 191 and 193 of the Indian Penal Code punishable with imprisonment upto seven years and fine, and Section 209 of Indian Penal Code punishable with imprisonment upto two years and fine. I have read and understood Sections 191, 193, 199 and 209 of the Indian Penal Code.

DEPONENT

Verification:

Verified at New Delhi on this ___ day of ___________ that the contents of the above affidavit relating to my assets, income and expenditure are true to my knowledge, no part of it is false and nothing material has been concealed therefrom, whereas the contents of the above affidavit relating to the assets, income and expenditure of my spouse are based on information believed to be true. I further verify that the copies of the documents filed along with the affidavit are the copies of the originals.

DEPONENT

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