SUPREME COURT OF THE STATE OF NEW YORK

COUNTY OF KINGS

-------------------------------------X	Index No.:

,

Plaintiff,	STATEMENT OF NET WORTH

(DRL Sec. 236)

-against-

,

Defendant.

------------------------------------X Date of commencement of action:

(Complete all items, marking “NONE”, “INAPPLICABLE” and “UNKNOWN” if appropriate)

STATE OF NEW YORK	COUNTY OF KINGS	SS.:

, the defendant herein, being duly sworn, deposes and says that the following is an accurate statement as of , of my net worth (assets of whatsoever kind and nature and wherever situated minus liabilities), statement of income from all sources and statement of assets transferred of whatsoever kind and nature and wherever situated:

FAMILY DATA:

Husband’s age	____ 46	_ (c)	Date married	12-28-86 _____

Wife’s age	____ 49_	(d)	Date separated	_ 04-17-2009 (no Legal Separtion) ____

(e)	Number of dependent children under 21 years __6__

(f)	Names and ages of children

_Talyah (21) Shani (19) Dovid (18) Itka (16) Aviva(13) Schmuel-Lieb(12)__ ______________________________

(g)	Custody of children ____2 Husband _____2

(h)	Minor children of prior marriage ____ Husband ____ Wife

(i)	Husband/Wife paying/receiving $______ as alimony (maintenance) and/or

$____ child support in connection with prior marriage

Custody of children of prior marriage:

Name_________________________________________

Address______________________________________

Is marital residence occupied __x_ Husband ___ Wife _ Both N/A

Husband’s present address

1163 East 15th Street Brooklyn, NY 11230

Wife’s present address

1804 State Route 13, Cayuta, NY

____________________________________________________________________

Occupation of Husband Pharmacist__________

Occupation of Wife _Medical Secretary________________

Husband’s employer

Kings Pharmacy

Wife’s employer

__Unknown_______________________________________________________________

Education, training and skills (include dates of attainment of degrees, etc.)

Husband_BS Pharmacist (1988) __Programmer (continual education)_______

Wife_____________

Husband’s health _____

Wife’s health _____

(s)	Children’s health __________________

II.	EXPENSES: (You may elect to list all expenses on a weekly basis or all expenses on a monthly basis, however, you must be consistent. If any items are paid on a monthly basis, divide by 4.3 to obtain weekly payments; if any items are paid on a weekly basis, multiply by 4.3 to obtain a monthly payment. Attach additional sheet, if needed. Items included under “Other” should be listed separately with separate dollar amounts.)

Expenses listed [ ] weekly [X] monthly

(a) Housing

1. Rent	$1500________	4. Condominium charges	_N/A____

2. Mortgage and	5. Cooperative apartment

maintenance

amortization	N/A_____

3. Real estate taxes

Total: Housing $ _$1500_______

(b) Utilities

1. Fuel oil	_inc____	4. Telephone _$35.00

2. Gas	inc	5.water INC

3. Electricity $300.00	6Internet $000

Total: Utilities $ 335________

(c) Food

1. Groceries	$500.0	. Liquor/Alcohol	$50.00___

2. School lunches	__N/___	6. Home entertainment	_0__

3. Lunches at work	$250	7.Other N/A

Total: Food	$ $800

(d) Clothing

1. Husband	_$0_______	3. Children _$0___

2. Wife	_	4. Other ________	_N/A____

Total: Clothing $ ________

(e) Laundry

1. Laundry at home	__0.00_	3. Other _$60_______	___N/A_

2. Dry cleaning	60.00

Total: Laundry $ 120

(f) Insurance

1. Life	___N/A__	6. Medical Plan	N/A

2. Homeowner/tenant	N/A	7. Dental Plan	__N/A__

3. Fire, theft and	8. Optical Plan	__N/A

liability	_N/A____	9. Disability	N/A

4. Automotive	N/	10. Worker's compensation N/A

5. Umbrella policy	________	11. Other ________	________

Total: Insurance $ ________

(g) Unreimbursed medical

1. Medical	000 Surgical, nursing,

2. Dental	00	hospital	__N/A______

3. Optical	N/A. Other________	____N/A____

4. Pharmaceutical	30

Total: Unreimbursed medical $ _30_______

(h) Household maintenance

1. Repairs	_INC. Painting	__N/A__

2. Furniture, furnishings,	6. Sanitation/carting	___N/A__

housewares	__$150___	7. Gardening/landscaping	__N/A___

3. Cleaning supplies	_80.00__	8. Snow removal	____N/A_

4.	Appliances, including	9. Extermination	__N/A

__INC___	10. Other________	________

Total: Household maintenance $ _$230________

(i) Household help

1. Babysitter	__N/A__	3. Other ______________	________

2. Domestic (maid,

housekeeper, etc.) __N/A

Total: Household help $ ________

(j) Automotive

Year: _Make: _unknown______ Personal: __ Business: ________

1. Payments	___N/A. Car wash	N/A

2. Gas and oil	__N/A_	5. Registration/license	_N/A ly

3. Repairs	__N/A	6. Parking and tolls	_N/A	7. Other_____________	________

Total: Automotive $ _________

(k) Educational / college

1. Nursery/pre-school	___0____	6. School transportation	________

2. Primary and secondary	___$00____	7. School supplies/books	_0.00__

3. College	___00 (Shani, Dovid and Talyah)__	8. Tutoring	___0_____

4. Post-graduate	___0____	9. School events	___$0_____

5. Religious instruction	___0_____	10. Other____________	________

Total: Educational $ ________

(l) Recreational

1. Summer camp	___$100____	9. Dining out __

2. Vacations	___$0____	10. Country club/pool club___0__

3. Movies	__$60____	11. Health club	__ 0 _

4. Theatre, ballet, etc.	___$40____	12. Sporting goods	____0___

5. Video rentals	___0____	13. Hobbies	____0.00

6. Tapes, CD's, etc	___0____	14. Music/dance lessons	____0____

7. Cable television	________	15. Sport lessons	____0____

8. Team sports	__ $10____	16. Birthday parties’	0.00___

17. Other ______________	________

Total: Recreational $ __$210_

(m) Income taxes

1. Federal	________	3. City	________

2. State	________	4. Social Security and	Medicare	________

Total: Income taxes $ ________

(n) Miscellaneous

1. Beauty parlor/barber	_10.00__	9.Union and organization

2. Beauty aids/ cosmetics	dues	________

drug items	__00.00	10. Communication and

3. Cigarettes/tobacco	_00.00_	transportation	200.00________

4. Books, magazines,	11. Vet/pet expenses 60.00___

newspapers	_00.00_	12. Child support payments

5. Children’s allowance	____80.00___	(prior marriage)	____0___

6. Gifts	_40.00__	13. Maintenance payments

7. Charitable donations	_100.00	(prior marriage)	____0____

8. Religious dues	__­­­­­0.00______	14. Loan payments	____0____

15. Unreimbursed business

expenses	___0_____

Total: Miscellaneous $ _490____

(0) Other

1. _________________	________	3. ________________	________

2. _________________	________	4. ________________	________

Total: Other $ ________

TOTAL EXPENSES: $ __3380______

III. GROSS INCOME: (State source of income and annual amount. Attach additional sheet, if needed)

(a) Salary or wages: Income has changed during the year (2009) preceding date of this affidavit. If so, set forth name and address of all employers during preceding year and average monthly wage paid by each. Indicate overtime earnings separately. Attach previous year's W-2 or income tax return.)

_ _______________

Just In Time Pharmacy

_ ______________________________________	$1800.00

________________________________________	________

(b) Monthly deductions:

1. Federal tax.................

2. New York State tax..........

3. Local tax...................

4. Social Security.............

5. Medicare....................

Other payroll deductions (specify)	$666.00

Employer refuses to give me a pay stub with tax break down but paid

me 283.50 cash a week based on a $450 a week pay agreement

______________________________

______________________

Kings Pharmacy $995.00

______________________________________

________________________________________	________

(b) Monthly deductions:

1. Federal tax.................	24.86

2. New York State tax..........	2.16

3. Local tax...................	17.62

4. Social Security.............	61.69

5. Medicare....................	14.43_

6. Other payroll deductions (specify)

______________________________

(c) Social Security Number 267-45-2995

(d) Number and names of dependents claimed:	0

(e) Bonus, commissions, fringe benefits (use of auto,

memberships etc.)..........	________

(f) Partnership, royalties, sale of assets

(income and installment payments).	________

(g) Dividends and interest

(State whether taxable or not).....	_______

(h) Real estate (income only)..........

(i) Trust, profit sharing and annuities

principal distribution and income)....	________

(j) Pension (income only)................	________

Awards, prizes, grants

(state whether taxable)..............	________

(l) Banquets, legacies and gifts.........

(m) Income from all other sources .......	________

(n) Tax preference items:

1. Long term capital gain deduction...	________

2. Depreciation, amortization or depletion	________

3. Stock options--excess of fair market

value over amount paid..........	________

(o) If any child or other member of your household is employed,

set forth name and that person's annual income

(p) Social Security.......................	________

(q) Disability benefits...................	________

(r) Public assistance.....................	________

(s) Other.................................	________

TOTAL INCOME: $	2795

IV. ASSETS: (If any asset is held jointly with spouse or another, so state, and set forth our respective shares. Attach additional sheets, if needed.)

A. Cash Accounts

Cash

1.1	a. Location__Wallet ___________

b. Source of funds__Work_________________________

c. Amount__________$40__________________________	$ ________

Total: Cash $ _40_______

Checking accounts

2.1	a. Financial Institution _ First Interent Bank of Indiana

b. Account number_162427200___________________________

c. Title holder __Ruben Safir___________________________

d. Date opened ____unknown__________________________

e. Source of Funds _paycheck _________________________

f. Balance___________________________________	$ _279.22_______

2.2	a. Financial Institution ____________________

b. Account number ___________________________

c. Title Holder _____________________________

d. Date opened_______________________________

e. Source of Funds __________________________

f. Balance___________________________________	$ ________

Total: Checking $ ________

Savings accounts (including individual, joint, totten trust, certificates of deposit, treasury notes)

3.1	a. Financial institution ____________________

b. Account number _______­­­­­­­­­­____________________

c. Title Holder _____________________________

d. Type of account __________________________

e. Date opened ______________________________

f. Source of funds __________________________

g. Balance __________________________________	$ ________

3.2	a. Financial institution ____________________

b. Account number ___________________________

c. Title Holder _____________________________

d. Type of account __________________________

e. Date opened ______________________________

f. Source of funds __________________________

g. Balance __________________________________	$ ________

Total: Savings $ ________

Security deposits, earnest money, etc.

4.1.	a. Location _________________________________

b. Title owner ______________________________

c. Type of deposit __________________________

d. Source of funds __________________________

e. Date of deposit __________________________

f. Amount____________________________________	$ _________

Total: Security Deposits, etc. $ ________

Other

5.1	a. Location_________________________________

b. Title owner______________________________

c. Type of deposit__________________________

d. Source of funds__________________________

e. Date of deposit__________________________

f. Amount___________________________________	$ ________

Total: Other	$ ________

Total: Cash Accounts $ ________

B. Securities

Bonds, notes, mortgages

1.1	a. Description of security__________________

b. Title Holder_____________________________

c. Location_________________________________

d. Date of acquisition______________________

e. Original price or value__________________

f. Source of funds to acquire_______________

g. Current value____________________________	$ ________

Total: Bonds, notes, etc. $ ________

Stocks, options and commodity contracts

2.1	a. Description of security _

b. Title Holder

d. Date of acquisition _

e. Original price or value _________________

f. Source of funds to acquire ______________

g. Current value __________________________	$ __________

Total Stocks, options, etc. $ ________

Broker margin accounts

3.1.	a. Name and address of broker_______________

b. Title Holder_____________________________

c. Date account opened______________________

d. Original value of account________________

e. Source of funds__________________________

f. Current value____________________________

Total: Margin accounts $ ________

Total value of securities $ ________

C. Loan to others and accounts receivable

1.1	a. Debtor's name and address__________________

b. Original amount of loan or debt ___________

c. Source of funds from which loan made or

origin of debt ____________________________

d. Date payment(s) due________________________

e. Current amount due_________________________	$ ________

Total: Loans and accounts receivable $ ________

D. Value of interest in any business

1.1	a. Name and address of business_______________

b. Type of business (corporate, partnership, sole

proprietorship or other)___________________

c. Your capital contribution__________________

d. Your percentage of interest________________

e. Date of acquisition________________________

f. Original price or value____________________

g. Source of funds to acquire_________________

h. Method of valuation________________________

i. Other relevant information_________________

j. Current net worth of business______________	$ ________

Total: Value of business interest $ ________

E. Cash surrender value of life insurance

1.1	a. Insurer's name and address_________________

b. Name of insured____________________________

c. Policy number______________________________

d. Face amount of policy______________________

e. Policy owner_______________________________

f. Date of acquisition________________________

g. Source of funding to acquire_______________

h. Current cash surrender value_______________	$ ________

Cash surrender value of life insurance: $ ________

F. Vehicles (automobile, boat, plane, truck, camper, etc.)

1.1	a. Description _ ___None___________________________

b. Title owner _______________________________

c. Date of acquisition________________________

d. Original price_____________________________

e. Source of funds to acquire ________________

f. Amount of current lien paid________________

g. Current fair market value__________________	$ ________

Total: Value of Vehicles $ ________

G. Real estate (including real property, leaseholds, life estates, etc. at market value -- do not deduct any mortgage)

1.1.	a. Description___	_________

b. Title owner________________________________

c. Date of acquisition_______________________

d. Original price_____________________________

e. Source of funds to acquire_________________

f. Amount of mortgage or lien unpaid____

g. Estimated current market value_____________	$ ________

Total: Value of real estate $ ______

H. Vested interest in trusts (pension, profit sharing, legacies, deferred compensation and others)

1.1	a. Description of trust _______________________

b. Location of assets _________________________

c. Title owner ________________________________

d. Date of acquisition_________________________

e. Original investment_________________________

f. Source of funds ____________________________

g. Amount of unpaid liens______________________

h. Current value_______________________________	$ ________

Total: Vested interest in trust $ ________

I. Contingent interests (stock options, interest subject to life estates, prospective inheritances, etc.)

1.1	a. Description_________________________________

b. Location____________________________________

c. Date of vesting_____________________________

d. Title owner_________________________________

e. Date of acquisition_________________________

f. Original price or value_____________________

g. Source of funds to acquire__________________

h. Method of valuation_________________________

i. Current value_______________________________	$ ________

Total: Contingent interests $ ________

J. Household furnishings

1.1	a. Description MISC. HOUSEHOLD FURNISHINGS_____

b. Location _1163 East 15th Street___________________

c. Title owner _Ruben Safir__________________

d. Original price_Furniture is old ____________

e. Source of funds to acquire _household income

g. Amount of lien unpaid_____none__________________

f. Current value________Less than 1,000.00_______________________	$ ________

Total: Household furnishings $ _$1000_______

K. Jewelry, art, antiques, precious objects, gold and precious metals (only if valued at more than $500)

1.1	a. Description MISC. PERSONAL Posters, Vases, Photographs__________

b. Title owner ________Ruben Safir________________________

c. Location ___________1163 East 15th Street________________________

d. Original price or value______$400_______________

e. Source of funds to acquire _Income________________

f. Amount of lien unpaid__N/A_____________________

g. Current value______N/A_________________________	$ ________

Total: Jewelry, art, etc.: $ _400_______

L. Other (e.g., tax shelter investment, collection, judgments, causes of action, patents, trademarks, copyrights, and any other asset not hereinabove itemized)

1.1	a. Description_________________________________

b. Title owner_________________________________

c. Location____________________________________

d. Original price or value_____________________

e. Source of funds to acquire__________________

f. Amount of lien unpaid_______________________

g. Current value_______________________________	$ ________

Total: Other $ ________

Total: Assets $ ___1400_____

V. LIABILITIES

A. Accounts payable

1.1	a. Name and address of creditor __Wisconcin Institute of Torah__

b. Debtor _ _Ruben and Ellen____________________________________

c. Amount of original debt _$42000____________________

d. Date of incurring debt ___3/1/2008__________________­_

e. Purpose Education of my Son

f. Monthly or other periodic payment _$00________

g. Amount of current debt ____4,200__________________	$ _$4200_______

1.2	a. Name and address of creditor Merkaz Bais Yaakov

b. Debtor Ruben and Ellen Safir _________________

c. Amount of original debt _$3600____________________

d. Date of incurring debt ___3/1/08__________________­_

e. Purpose Education of Itka

f. Monthly or other periodic payment __$200_________

g. Amount of current debt _2,800____________________	$ ___2.800_____

1.3	a. Name and address of creditor__Robert Ward

b. Debtor__Ruben Safir _ ___________________________________

c. Amount of original debt $7500

d. Date of incurring debt__3/31/09____________________

e. Purpose___Rent__________________________________

f. Monthly or other periodic payment_0__________

g. Amount of current debt______________________	$ _7500_______

1.4	a. Name and address of creditor_ Camp Sternberg

b. Debtor _ ______________________________________

c. Amount of original debt______1825________________

d. Date of incurring debt_______6-1-09________________

e. Purpose_______Camp for Aviva_______________________________

f. Monthly or other periodic payment____________

g. Amount of current debt______________________	$ _1325_______

1.5	a. Name and address of creditor ___Wolff Grocery________________

b. Amount of original debt________3500_______________

c. Date of incurring debt_________1-1-1994_______________

d. Purpose_______________________________________

e. Monthly or other periodic payment_____________

f. Amount of current debt________________________ $ _3800_______

1.6	a. Name and address of creditor __”Coin Talk” Community_________________

b. Amount of original debt________$1800_______________	c. Date of incurring debt_________5-1-2009_____________	d.Purpose Loan to help support kids and maintain housing by

internet communty fund raising

e. Monthly or other periodic payment_____________

f. Amount of current debt________________________ $ _1800_______

1.7	a. Name and address of creditor ___Arnold Lubitz 2304 Nostrand Avenue	b. Amount of original debt________$500_______________

c. Date of incurring debt_________02-01-2009_______________

d. Purpose______Pay for Shoshana's College________________________

e. Monthly or other periodic payment_____________

f. Amount of current debt________________________ $ _500_______

1.8	a. Name and address of creditor ___Consolidated Edison________________

b. Amount of original debt________$350_______________

c. Date of incurring debt_________02-01-2009_______________

d. Purpose___________Electric Bill Desposit____________________________

e. Monthly or other periodic payment_____________

f. Amount of current debt________________________ $ _350_______

1.9	a. Name and address of creditor ___Maimonedes Hospital________________

b. Amount of original debt________$1200_______________

c. Date of incurring debt_________05-12-2009_______________

d. Purpose____Shoshana Rivkah ER visit for Kidney Stone_

e. Monthly or other periodic payment_____________

f. Amount of current debt________________________ $ __1200______

1.10	a. Name and address of creditor ___Shoshana Safir________________

b. Amount of original debt________$1000_______________

c. Date of incurring debt_________05-1-2009_______________

d. Purpose____To Pay Rent_

e. Monthly or other periodic payment_____________

f. Amount of current debt________________________ $ __1000______

1.11	a. Name and address of creditor ___Lewis Travel________________

b. Amount of original debt________$570_______________

c. Date of incurring debt_________06-04-2009_______________

d. Purpose____Air Plane Tickets for Dovids Graduation_

e. Monthly or other periodic payment_____________

f. Amount of current debt________________________ $ _570______

1.12	a. Name and address of creditor Arnot Ogdon Medical Center_______________

b. Amount of original debt________$5000_______________

c. Date of incurring debt_________01-01-2009_______________

d. Purpose____Employment Bonus Loan _

e. Monthly or other periodic payment_____________

f. Amount of current debt________________________ $ __5000______

1.12	a. Name and address of creditor Rite-Aid______________

b. Amount of original debt________$5000_______________

c. Date of incurring debt_________06-2006_______________

d. Purpose____Employment Bonus Loan _

e. Monthly or other periodic payment_____________

f. Amount of current debt________________________ $ __5000______

Total: Owed $ __35945______

Total: Owed $ _

E. Mortgages payable on real estate

1.1	a. Name and address of mortgagee__________________

b. Address of property mortgaged__________________

c. Mortgagor(s) ___________________________________

d. Original debt__________________________________

e. Date of incurring debt_________________________

f. Monthly or other periodic payment______________

g. Maturity Date__________________________________

h. Amount or current debt_________________________ $ ________

Total: Mortgages payable on real estate $ ________

F. Taxes payable

1.1.	a. Description of tax_____________________________

b. Amount of tax__________________________________

c. Date due_______________________________________

Total: Taxes payable $ ________

G. Loans on life insurance policies

1.1.	a. Name and address of insurer____________________

b. Amount of loan_________________________________

c. Date incurred__________________________________

d. Purpose________________________________________

e. Name of borrower_______________________________

f. Amount of current debt_________________________

g. Monthly or other periodic payment______________

h. Amount of current debt_________________________ $ ________

Total: Loans on life insurance policies $ ________

H. Other liabilities

1.1	a. Description____________________________________

b. Name and address of creditor___________________

c. Debtor_________________________________________

d. Original amount of debt________________________

e. Date incurred__________________________________

f. Purpose________________________________________

g. Monthly or other periodic payment______________

h. Amount of current debt_________________________

Total: Other liabilities $ ________

TOTAL LIABILITIES: $ ________

NET WORTH

TOTAL ASSETS:	$ ________

TOTAL LIABILITIES:	(minus) $ ________

NET WORTH	$ ________

VI. ASSETS TRANSFERRED:	(List all assets transferred in any manner during the preceding three years, or length of the marriage, whichever is shorter (transfers in the routine course of business which resulted in an exchange of assets of substantially equivalent value need not be specifically disclosed where such assets are otherwise identified in the statement of net worth).

Description	To Whom Transferred	Date of	Value

Of Property	and Relationship to	Transfer

Transferee

_____________	____________________	________ ________

_____________	____________________	________ ________

_____________	____________________	________	________

_____________	____________________	________	________

VII. SUPPORT REQUIREMENTS:

(a) Deponent is at present (paying) (receiving) $ _______per (week) (month) to cover expenses for ______________________________________________________________________________

These payments are being made (voluntarily) (pursuant to court order or judgment) (pursuant to separation agreement), and there are (no) arrears outstanding (in the sum of $............ to date).

(b) Deponent requests for support of each child $ ________ per (week) (month). Total for children $ ________

VIII. COUNSEL FEE REQUIREMENTS:

(a) Deponent requests for counsel fee and disbursements the sum of $ ________.

(b) Deponent has paid counsel the sum of $ ________and has agreed with counsel concerning fees as follows:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

(c) There is (not) a retainer agreement or written agreement relating to payment of legal fees. (A copy of any such agreement must be annexed.)

IX. ACCOUNTANT AND APPRAISAL FEES REQUIREMENTS:

(a) Deponents request for accountants' fees and disbursements the sum of $ ________

(b) Deponent request for appraisal fees and disbursements the sum of $ ________ (Include basis for fee, e.g., hourly rate, flat rate)

(c) Deponent requires the services of an accountant for the following reasons:

______________________________________________________________________________________

______________________________________________________________________________________

(d) Deponent requires the services of an appraiser for the following reasons:

______________________________________________________________________________________

______________________________________________________________________________________

X. Other data concerning the financial circumstances of the parties that should be brought to the attention of the court are:

____________________________________________________________________________________________

____________________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

The foregoing statements and a rider consisting of 11 page(s) annexed hereto and made part hereof, have been carefully read by the undersigned who states that they are true and correct.

____________________________

Ruben Safir

Sworn to before me this

day of July 10th, 2009

CERTIFICATION OF ATTORNEY

I hereby certify under penalty of perjury and as an officer of the court that I have no knowledge that the substance of any of the factual submissions contained in this document is false.

________________________________________

(The name signed must be printed beneath)

ROBERT A. UGELOW, P.C.

by ROBERT A. UGELOW, ESQ.

Dated: August , 2003

13

SUPREME COURT OF THE STATE OF NEW YORK

Robert A. Ugelow

2009-07-10T10:31:00