Here is the text we could read:
FINANCIAL STATEMENT
OF JUDGMENT DEBTOR
DOCKET NUMBER
CASE NAME
NAME OF JUDGMENT DEBTOR (the person who lost the case and owes money)
Trial Court of Massachusetts
Small Claims Session
COURT DIVISION
(cid:2)(cid:3)BOSTON MUNICIPAL COURT ________ Division
(cid:2)(cid:3)DISTRICT COURT ________ Division
(cid:2)(cid:3)HOUSING COURT ________ Division
HOME ADDRESS
HOME TELEPHONE NUMBER
DATE OF BIRTH
SOCIAL SECURITY NUMBER
DRIVER’S LICENSE NUMBER & STATE
MARITAL STATUS
NO. & AGE OF CHILDREN LIVING WITH YOU
OCCUPATION
EMPLOYER’S NAME & ADDRESS
HOW LONG WITH EMPLOYER?
INCOME (list all sources)
ASSETS (list value of all assets)
Your Gross Pay:
$ ........................ per week
Real Estate you own or co-own
RESIDENCE
OTHER
Your Take-Home Pay:
$ ........................ per week
Address:
...............................................
Spouse’s Take-Home Pay:
$ ........................ per week
Other Owner(s):
................................................
Child Support Income:
$ ........................ per week
Mortgage Balance:
$ ..................
$ ..................
Pension:
AFDC/SSI:
$ ........................ per week
Fair Market Value:
$ ..................
$ ..................
$ ........................ per week
Rental Income:
$ ..................
$ ..................
Other (itemize on back):
$ ........................ per week
Vehicle(s)/Boat(s) You Own
VEHICLE/BOAT 1
VEHICLE/BOAT 2
Total Weekly Income:
$ ........................ per week
Year/Make & Model:
................................................
EXPENSES
Purchase Year:
................................................
Purchase Price:
$ ..................
$ ..................
Rent/Mortgage:
$ ........................ per week
Amount Owed:
$ ..................
$ ..................
$ ........................ per week
Bank Accounts
CHECKING
SAVINGS
$ ........................ per week
Bank/Credit Union:
................................................
Alimony/Child Support:
$ ........................ per week
Utilities:
Food:
Child Care:
Transportation:
Insurance:
$ ........................ per week
$ ........................ per week
$ ........................ per week
Entertainment (including cable): $ ........................ per week
Other (itemize on back):
$ ........................ per week
Total Weekly Expenses:
$ ........................ per week
Account No.:
Balance:
................................................
$ ....................... $ ..................
Expected Tax Refund:
$ ...............................................
How much money do you have in cash? $ ................................
Have you disposed of or transferred any asset since this claim was
brought? (If so, explain on back.) (cid:2) No (cid:2) Yes
(List on back anything of value not listed above that you own or
co-own, or that is held for you by another.)
DEBTS (list all debts not included above in your expenses – e.g., credit card debts)
CREDITOR
NATURE OF DEBT
DATE OF ORIGIN
TOTAL DUE
WEEKLY PAYMENT
1 ..............................................................................................................................................
$ ...................... $ ....................
2 ..............................................................................................................................................
$ ...................... $ ....................
3 ..............................................................................................................................................
$ ...................... $ ....................
Under the penalties of perjury, I swear that the above information is complete and accurate to the best of my personal knowledge.
DATE SIGNED
SIGNATURE OF JUDGMENT DEBTOR
X
Pursuant to Uniform Small Claims Rule 9(c), all information in this affidavit is CONFIDENTIAL.
It shall be available to any other party to this litigation, but shall not be available for public inspection unless the Court so orders.
Financial Statement of Judgment Debtor English 11/18 https://www.mass.gov/topics/court-forms
INCOME AND PROPERTY
THAT ARE
EXEMPT FROM PAYMENT ORDERS
(This list of exempt income and property is not comprehensive. It is provided to assist the court in avoiding
the issuance of orders that would require payment from exempt sources. When requesting a payment
order, the creditor bears the burden of proving that the debtor has sufficient non-exempt income or
property with which to satisfy the judgment. See G.L. c. 224, § 16.)
1. INCOME FROM THE FOLLOWING SOURCES is exempt by law from payment orders:
• Unemployment Benefits (G.L. c. 151A, § 36)
• Workers Compensation Benefits (G.L. c. 152, § 47)
• Social Security Benefits (42 U.S.C. § 401)
• Federal Old-Age, Survivors & Disability Insurance Benefits (42 U.S.C. § 407)
• Supplementary Security Income (SSI) for Aged, Blind & Disabled (42 U.S.C. § 1383[d][1])
• Other Disability Insurance Benefits up to $400 weekly (G.L. c. 175, § 110A)
• Emergency Aid for Elderly & Disabled (G.L. c. 117A)
• Veterans Benefits
• Federal Veterans Benefits (38 U.S.C. § 5301[a])
• Special Benefits for Certain WW II Veterans (42 U.S.C. § 1001)
• Medal of Honor Veterans Benefits (38 U.S.C. § 1562)
• State Veterans Benefits (G.L. c. 115, § 5)
• Transitional Aid to Families with Dependent Children (AFDC) Benefits (G.L. c. 118, § 10)
• Maternal Child Health Services Block Grant Benefits (42 U.S.C. § 701)
• Other public assistance benefits (G.L. c. 235, § 34, cl. fifteenth)
• Payouts from certain Massachusetts employee pension plans (G.L. c. 32, § 19)
2. Certain PERSONAL AND REAL PROPERTY is also exempt from payment orders, including:
• $2,500 in cash or savings or other deposits in a banking or investment institution (G.L. c. 235, § 34, cl.
fifteenth)
• Automobile or vehicle up to exemption limit (G.L. c. 235, § 34, cl. sixteenth)
• Other specific types of personal property are exempt under other clauses of G.L. c. 235, § 34
• Real estate subject to automatic or declared homestead exemption (G.L. c. 188) and, in lieu thereof, the
amount of money necessary for rent, up to $2,500 per month (G.L. c. 235, § 34, cl. fourteenth)
• There are also exemptions for “aggregate” amounts, up to maximum limits, of certain unused exemptions
(G.L. c. 235, § 34, cl. seventeenth)
3. In addition, A PORTION OF WAGES AND CONTRIBUTIONS TO EMPLOYMENT-BASED
RETIREMENT PLANS is exempt by law from payment orders.
Massachusetts law exempts the greater of 85% of the debtor’s gross earnings or 50 times the greater of
the Federal minimum wage ($7.25 as of 7/24/09) or the Massachusetts minimum wage ($11/hr. until
12/31/18 per G.L. c. 151, § 1; $12/hr. as of 1/1/19; $12.75/hr. as of 1/1/20; $13.50/hr. as of 1/1/21;
$14.25/hr. as of 1/1/22; and $15/hr. as of 1/1/23) for each week or portion thereof (G.L. c. 224, § 16 & c.
235, § 34, cl. fifteenth). The amount exempt under federal law (15 U.S.C. §§1671-1677) may exceed the
Massachusetts exemption. If so, the federal exemption applies.
See Worksheet for Computing Amount of Wages Exempt From Attachment, Execution and Payment
Orders. https://www.mass.gov/media/910531/download/
Rev. 11/18
