S. 

No.

Description

Particulars

1.

Name

……………

2.

Age

…….. years

3.

Residential Address

…………………………………………….. ……………………………………………..

4.

E-mail Address

…………………….

5.

Date of marriage

……20..

6.

Date of separation

……20..

7.

Educational qualifications

………………..

8.

Professional qualifications

……………..

9.

Occupation

.

10.

Monthly income (as mentioned at  serial no.45)

………………

11.

Monthly expenditure (as  mentioned at serial no.60)

……………….

12.

Whether you are assessed to  Income Tax?

Yes/No

13.

Whether you have sufficient  income to support yourself?

Yes/No

14.

If not, whether you have claimed  maintenance from your spouse?

Yes/No

15.

Whether you are staying at  matrimonial home?

Yes/No

16.

If not staying at matrimonial home,  relationship and income of the  person with whom you are staying.

………………………………………………… ………………………………………………… ………………….

17.

Members of the family: 

(a) Dependent

(b) Non-dependent

………………………………

18.

Whether your spouse has claimed  maintenance from you? If so, how  much?

N.A.

19.

Whether you have voluntarily paid  or willing to pay maintenance to  your spouse? If so, how much?

N.A.

20.

Whether you are willing to pay  litigation expenses to your spouse?  If so, how much?

Yes/No

21.

Particulars of pending litigation  between the parties

(i) ……………………………………………

(ii)…………………………………………… (iii) …………………………………….

22.

Whether any maintenance order  has been passed by any Court? If  so, give particulars and attach copy  of the order?

Yes/No

23.

Whether the maintenance is being  paid in terms of the aforesaid  order? If so, file the statement of  maintenance paid upto date

Yes/No

24.

Expenses incurred on this litigation

Approx. Rs. ………………………

25.

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.

26.

Name of your counsel and his/her ……………………………

mobile number and e-mail address

……………………………….

Email: …………………………

Ph. …………………………

S. No.

Description

Particulars

27.

Educational and professional qualifications of  your spouse

28.

Whether your spouse was/is earning? If so, give  particulars of the occupation and income of your  spouse.

Yes/No

29.

Whether your spouse is staying at matrimonial  home. If not, whether he/she is staying at his/her  own accommodation or at a rented 

accommodation? If staying at a rented  accommodation, what is the rent being paid by  him/her?

Yes/No

30.

Particulars of the assets and liabilities of your  spouse

Yes/No

31.

Do you have any documents relating to the  income, assets and expenditure of your spouse?  If so, give the particulars and attach copies  thereof?

Yes/No

S. No.

Description

Particulars

32.

Children from the marriage with their name and  age

Yes/No

33.

Who has the custody of the minor children

34.

Name and address of school(s) where the  children are studying

35.

Who is bearing the expenditure of Children’s  education

36.

How much expenditure has been incurred on the  children’s maintenance and children’s education  from the date of separation till now?

37.

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?

38.

Details of expenditure on children Amount

(i) School/College fees

(ii) Crech/Day Care/After school care

(iii) Books/Stationery

(iv) Private Tuitions

(v) Pocket Money/Allowances

(vi) Sports

(vii)Outings/summer camps/vacations

(viii) Entertainment

(ix) Others

39.

TOTAL EXPENDITURE (Give monthly  expenditure)

S. No.

Description

Particulars

40. In case of salaried persons:

Designation

Name and address of the employer

Date of employment

Gross Income including the salary, D.A.,  commissions/incentives, bonus, perks etc.

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

Deductions from the gross income

Income Tax paid

Net income

Value of stock option benefits if provided by the  employer

Pension and retirement benefits payable at the  time of retirement

41.

In case of self-employed persons:

Nature of business/profession

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 in 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

Number of employees

Annual turnover/gross receipts

Gross Profit

Net Income

Income Tax

Details and value of benefits in kind, perks or  other remuneration e.g. provision of car,  payment of accommodation etc.

Amount of regular monthly withdrawal or  drawings

42.

In case the business/ profession is carried on as  a Partnership Firm/Company :

Registered /Corporate Office of the

firm/company

Information and particulars with regard to your  shareholding, involvement in the affairs and  management of the firm/company

Director’s/ Partner’s remuneration : –

a) Salary

b) Interest

c) Rent

d) Commission

e) Others

List of all the bank accounts of the  firm/company

Location of the statutory records and books of  account of the firm/company

List of immovable assets, land and building etc.  of the firm/company.

Number of workmen/employees

Current value of your business interest(s)

Current value of your business assets

List of directorships held, sitting fees,  commission or any other remuneration

Net worth of the company in which you are  Director along with the number of shares held in  the Company

43.

Income from Other Sources :

Agricultural Income

Rent

Interest on bank deposits and FDRs

Interest on investments including deposits,  NSC, IVP, KVP, Post Office schemes, PPF,  loans etc.

Dividends

Mutual Funds

Annuities

Lease of machinery, plant or furniture

Sale of movable/ immovable assets

Gifts

44.

Any other income not covered above

45.

TOTAL INCOME (Give monthly income)

S. No.

Description

Particulars

46.

Housing

(i) Monthly rent

(ii) Mortgage payment(s)

(iii) Repairs & Maintenance

(iv) Property tax

47.

Household 

expenditure

(i) Groceries/Food items/  Personal care/clothing

(ii) Water

(iii) Electricity

(iv) Gas

(v) Telephone/Mobile

(vi) TV Cable/Set-top Box  charges & Internet services

(vii) Maintenance, 

replacement and repair of  household items, appliances  and kitchenware.

(ix) Domestic full time/part  time helper(s)

(x) Others (specify)

48.

Maintenance of  Dependents

(i) Parents

(ii)Children (as mentioned  at serial no.39)

(iii) Others

49.

Transport

(i) Private Transport

 (a) Driver(s)

 (b) Fuel

 (c) Repair/Maintenance

 (d) Insurance

 (e) Loan repayment

(ii) Public Transport

 (a) Bus

 (b) Taxi

 (c) Metro

 (d) Auto

50.

Medical 

expenditure

(i) Doctor’s Charges

(ii) Medication

(iii) Hospital

(iv) Other medical 

expenditure

(v) Others (specify)

51.

Insurance

(i) Life

(ii) Annuity

(iii) Householders

(iv) Medi-Claim

52.

Entertainment 

and recreation

(i) Club

(ii) Health Club

(iii) Gym

53.

Holiday and vacations

54.

Gifts

55.

Legal/litigation expenses

56.

Discharge of 

Liabilities

(i) Credit card(s) payment

(ii) Hire purchase/lease

(iii) Repayment of Loans

 (a) House loan

 (b) Car loan

 (c) Personal loan

 (d) Business loan

 (e) Any other loan

(iv) Name of the lenders

(v) Mode of repayment

(vi) Instalment amount

(vii)Other personal 

liabilities

57.

Miscellaneous

(i) Newspapers, magazines,

books

(ii) Religious contributions/  Charities

(iii) Others (specify)

58.

Pocket Money/Allowance

59.

Other expenditure (Teacher Training Course)

60.

TOTAL EXPENDITURE (Give monthly  expenditure)

S. 

No.

Assets

List of Assets

At the 

time of 

marriage

At the 

time of 

Separatio n

Present

Present 

Estimated  Market 

Value

61.

Real Estate Including

Land

Built up properties

Lease hold properties

Agricultural land

Investment in real  estate such as booking  of plots, flats and other  immovable properties  in your name or in  joint names.

Other properties

Note 1. : – List your interest in properties, including lease hold interest and  mortgages, whether or not you are registered as owner.

Note 2. : – Provide legal descriptions and indicate estimated market value of  your interest without deducting encumbrances or costs of disposition. (Record  encumbrances under debts.)

62.

Joint Properties

N.A.

Properties presented at  or about the time of  marriage, which

belong jointly to both  the husband and wife.  Give the status of their  possession.

Other joint properties  of the parties. Give the  status of their  possession.

Whether any litigation  pending with respect  to the joint property?  If so, give particulars.

63.

Liquid Assets:  

(i) Details of all bank  accounts including  Current, Savings  and Demat  Accounts in your  name, or joint name  and balance in the  said account

Account 

Number

Name of the  Bank

Current 

Balance

(i)

(ii)

(iii)

(iv)

(ii) Cash in hand

64.

Investments: Details  of all investments you  hold or, in which you  have interest and their  current value:

Particulars

Current Value

FDRs, NSC, IVP,  KVP, Post Office  schemes, PPF etc.

Deposits with  Government and Non Government entities

Stocks, shares,  debentures, bonds,  units and mutual  funds, etc.

Life and endowment  policies and surrender  value

Loan given to friends,  relatives and others

Other investments not  covered by above  items

65.

Pensions and  Retirement Savings  Plan

Indicate name of  institution where  accounts are held,  name and address of  pension plan and  pension details

Particulars

Maturity Amount

66.

Corporate/Business  Interests

List any interest you  hold, directly or  indirectly, in any  corporation, 

unincorporated 

business, partnership,  trust, joint venture and  Association of  Persons, Society etc.

Particulars

Current Value

67.

Movable Assets

Particulars

Current Value

Motor Vehicles (List  cars, motorcycles,  scooters etc. along

with their brand and  registration number)

Livestock

Mobile phone(s)

Computer/Laptop

Other electronic  gadgets including I – pad etc.

TV, Fridge, Air  Conditioner, 

Microwave, Washing  machine, etc. (all with  the Respondent in  Delhi/ Dubai)

Other household and  kitchen appliances

Quantity of gold, platinum, silver and  diamond jewellery

p

 All Jewellery in Possession of the Respondent.

Quantity of Silver  Utensils

 All Silver utensils in Possession of The Respondent.

68.

Intangible properties Including patents,  trademark, copyright  design and goodwill  and their value

Particulars

Present Estimated  Market Value

N.A.

69.

About disposal of  properties

Particulars of  properties (movable as  well as immovable)  sold/agreed to be sold  between the date of  marriage till the date  of filing of this  affidavit and the sale  consideration received  from the purchaser

Particulars

Present Estimated  Market Value

70.

Others

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 safety  deposit lockers.

Particulars

Estimated Current  Value

S. No.

Description

Particulars of  Debts

Current Value

71.

Secured debt(s)

List all mortgages, loans, and

any other debts secured against  an asset

72.

Unsecured Debt(s)

List all bank loans, personal  loans, credits, overdrafts, credit  cards and any other debts

73.

Other

List any other debts, including  obligations that are relevant to a  claim

S. No.

Description

Particulars

74.

Particulars of residential 

accommodation where your are  presently staying (in sq. feet)

75.

Who is the owner of the residential  accommodation? In case of rented  accommodation, specify the monthly  rent

76.

Number of part-time/full time domestic  helpers and their wages

77.

Average monthly withdrawal from  bank(s)

78.

Mode of travel in city/outside city

79.

Membership of clubs/health 

clubs/gyms, societies and other  associations. Specify the membership  fee and subscription

80.

Particulars of credit/debit card(s), its  limit and usage

81.

Particulars of frequent flier cards

—

82.

Frequency of foreign travel, business

as well as personal

83.

Category of hotels ordinarily used for  stay, official as well as personal

84.

Category of hospitals opted for medical  treatment including type of rooms

85.

Brand of vehicle, mobile and wrist  watch, pen, sunglasses, wallet/bags.

86.

Expenditure ordinarily incurred on  family functions including birthday of  the children

87.

Expenditure ordinarily incurred on  festivals

88.

Expenditure incurred on marriage of  family members

89.

Status of the deponent and his/her  family: –

∙ High

∙ Upper Middle

∙ Middle

∙ Lower Middle

∙ Low

∙ Below poverty line

PART A

DOCUMENTS RELATING TO PERSONAL INFORMATION

S. No.

Descriptions

1.

Ration Card

2.

Voter ID Card

3.

Aadhar Card

4.

Driving Licence

5.

PAN Card

6.

Passport

PART B

DOCUMENTS RELATING TO INCOME, ASSETS AND LIABILITIES

S. No.

Description

Please Tick

Attached

Not Applicable

To follow

7.

Statement of Account of  all bank accounts 

including current, savings  and Demat accounts for  last 3 years

8.

Income Tax Return(s)  along with Statement of  Income for last 3 years

9.

In case of Salaried  

Persons

Appointment letter along  with salary structure at  time of appointment.

Last Salary Slip

Forms 16, 16A , 12BA &  26AS

Cost to Company 

Certificate and CIBIL  Certificate, wherever 

applicable

Copies of TDS certificates

10.

In case of self-employed  persons

Balance Sheet and Profit  & Loss Account

Balance Sheet and Profit  & Loss Account of the  proprietorship firm, if the  business is carried on in  the name of a sole 

proprietorship concern

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

Balance Sheet and Profit  & Loss Account of the  Company in which the  deponent is a Director

Balance Sheet and Profit  & Loss Account of the  Association of Persons,  HUF, Joint Family  business or trust in which  the deponent has share

Copy of account of the  deponent in the books of  the business

Copies of TDS certificates

11.

In case of Income from  other sources:

Lease Deed(s)/Rent  Agreement(s) /Licence  Agreement(s) in respect of  the rental income

Interest Certificate in  respect of the interest  income on deposits and  investments

Dividend Certificates in  respect of dividend income

Demat holding Statement

Sale Deed(s)/transfer  documents in respect of  the profit on sale of  property/properties

12.

Other relevant documents  relating to Income/Assets

13.

Other relevant documents  relating to liabilities

PART C

DOCUMENTS RELATING TO EXPENDITURE

14.

Description

Please Tick

Attached

Not Applicable

To Follow

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

Rent and maintenance  receipts

Electricity, water, security  and gas bills

Documents relating to the  salary paid to the  employees including  domestic helper(s)

Documents relating to  expenditure on  conveyance

Debit and Credit Card  statements of all cards

Frequent Flier’s Card  statements

Mobile and landline phone  bills

Internet and TV cable/ Set

– Top Box bills

Documents relating to the  re – payment of the loans

PPF, EPF and other  superannuation fund  receipts

Receipts of premium of  insurance policies

Receipts of payments in  respect of mutual funds

Documents relating to  payment of interest on  bank and other loans

Documents relating to the  payment of taxes,  including Income Tax and  Property Tax

Other relevant documents  relating to Expenditure