The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02

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Here is the text we could read:

FINANCIAL STATEMENT

......................................................................
     Social Security Number
Name

   Date of Birth

......................................................................
Address

Telephone Number

......................................................................
Employer

Employer’s Address

......................................................................
Position held

Employer’s Telephone Number

If unemployed:

How long.............Why .............................................

Previous Employer ..............................Position .............

Physical or mental disability ........................................

Income

Assets

$....................last year
Gross Pay $..............,weekly
Net Pay $................weekly
$....................per month
Social Security, pension, retirement income $..............per month
Unemployment disability, worker’s compensation $...........per month
Public assistance (Welfare, AFDC, SSI, VA) $...............per month
Child support or alimony income $...........weekly $.......per month
Other income $.......................Source ..........................
......................................................................

Property owned .................................Value $...............
P.I.T. payments $..............................Bal. Due $.............
Name of Bank ..................................Mtg. Bal.$.............

Car .....................Year and make .............Value $...........

Bank accounts .....Checking $..............Savings $..................

Names of banks .......................................................
......................................................................

Other assets .........................................................
......................................................................
......................................................................
......................................................................

Liabilities

2

......................................................................
......................................................................
......................................................................
......................................................................

Current Income and Expenses (from all sources)

Gross (weekly) (monthly) income $ ...............................

Federal tax ..........................
State tax ............................
Social Security ......................
Health Insurance .....................
Pension ..............................
Other ................................
......................................
......................................
......................................

Total Deductions $.........................

Net (weekly) (monthly) income $ .................

Rent $................................
Heat $................................
Gas $ ................................
Electric $ ...........................
Food $ ...............................
Clothing $ ...........................
Other $ ..............................
......................................
......................................

Total Expenses $............................

Net Income minus expenses $ .....................

Persons Living with you: .............................................

Other facts relevant to ability to pay: ..............................
......................................................................
......................................................................
......................................................................

Signed under the penalties of perjury:

______________________________________
Name: ________________________________
Address: _____________________________
     ______________________________________

Telephone No. ________________________ 

Date: ................

Financial Statement - Housing Court

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Massachusetts state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.mass.gov (2023-03)
Page(s): 2
Fields(s): 75
Average fields per page: 37
Reading Level: Grade 11
LIST Grouping(s): GO-00-00-00-00.

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

submitted_financial_statement__1 was SubmittedBy_FinancialStatement1 (0.68 conf)
submitted_financial_statement__2 was SubmittedBy_FinancialStatement2 (0.48 conf)
submitted_name_address was SubmittedBy_EmployerName&Address1 (0.41 conf)
submitted_employer_info was SubmittedBy_EmployerInfo1 (0.40 conf)
submitted_unemployed_time was SubmittedBy_UnemployedTime (0.45 conf)
submitted_unemployed_reason was SubmittedBy_UnemployedReason (0.45 conf)
previous_employer_name was SubmittedBy_PreviousEmployerName (0.34 conf)
submitted_previous_position was SubmittedBy_PreviousPosition (0.44 conf)
submitted_disabilities was SubmittedBy_Disabilities1 (0.41 conf)
submitted_gross_pay was SubmittedBy_GrossPay (0.45 conf)
submitted_previous_yr_gross_annual_income was SubmittedBy_PreviousYrGrossAnnualIncome (0.39 conf)
submitted_net_pay was SubmittedBy_NetPay (0.38 conf)
submitted_net_pay_amount was SubmittedBy_NetPayAmount (0.43 conf)
pension_retirement_amount was SubmittedBy_SocialSecurityPensionRetirementAmount (0.41 conf)
unemployment_disability_workers was SubmittedBy_UnemploymentDisabilityWorkersCompAmount (0.43 conf)
public_assistance_amount was SubmittedBy_PublicAssistanceAmount (0.49 conf)
support_amount_weekly was SubmittedBy_ChildSupportAlimonyAmount_Weekly (0.38 conf)
support_amount_monthly was SubmittedBy_ChildSupportAlimonyAmount_Monthly (0.38 conf)
submitted_income_amount__1 was SubmittedBy_OtherIncomeAmount (0.44 conf)
submitted_income_source was SubmittedBy_OtherIncomeSource (0.34 conf)
text__1 was Text318 (0.35 conf)
text__2 was Text319 (0.35 conf)
text__3 was Text320 (0.35 conf)
submitted_pi_tpayment_amount was SubmittedBy_PITpaymentAmount (0.42 conf)
submitted_amount_balance was SubmittedBy_PITpaymentAmountBalance (0.42 conf)
text__4 was Text324 (0.35 conf)
text__5 was Text322 (0.35 conf)
submitted_car was SubmittedBy_Car (0.44 conf)
submitted_car_year_make was SubmittedBy_CarYear&Make (0.36 conf)
submitted_car_market_value was SubmittedBy_CarMarketValue (0.48 conf)
submitted_checking_amount was SubmittedBy_CheckingAmount (0.42 conf)
submitted_savings_amount was SubmittedBy_SavingsAmount (0.35 conf)
bank_name__1 was Bank_Name1 (0.48 conf)
bank_name__2 was Bank_Name2 (0.48 conf)
submitted_assets__1 was SubmittedBy_OtherAssets1 (0.45 conf)
submitted_assets__2 was SubmittedBy_OtherAssets2 (0.45 conf)
submitted_assets__3 was SubmittedBy_OtherAssets3 (0.45 conf)
submitted_assets__4 was SubmittedBy_OtherAssets4 (0.45 conf)
submitted_liabilities__1 was SubmittedBy_Liabilities1 (0.41 conf)
submitted_liabilities__2 was SubmittedBy_Liabilities2 (0.41 conf)
submitted_liabilities__3 was SubmittedBy_Liabilities3 (0.41 conf)
submitted_liabilities__4 was SubmittedBy_Liabilities4 (0.41 conf)
submitted_gross_income was SubmittedBy_GrossIncome (0.41 conf)
submitted_federal_tax was SubmittedBy_FederalTax (0.37 conf)
submitted_state_tax was SubmittedBy_StateTax (0.37 conf)
submitted_social_security was SubmittedBy_SocialSecurity (0.38 conf)
submitted_health_insurance was SubmittedBy_HealthInsurance (0.46 conf)
submitted_pension was SubmittedBy_Pension (0.39 conf)
submitted_income_amount__2 was SubmittedBy_OtherIncomeAmount1 (0.43 conf)
submitted_income_amount__3 was SubmittedBy_OtherIncomeAmount2 (0.43 conf)
submitted_income_amount__4 was SubmittedBy_OtherIncomeAmount3 (0.43 conf)
submitted_income_amount__5 was SubmittedBy_OtherIncomeAmount4 (0.43 conf)
submitted_total_deductions was SubmittedBy_TotalDeductions (0.45 conf)
submitted_net_income was SubmittedBy_NetIncome (0.40 conf)
rent_rate was Rent_Rate (0.41 conf)
submitted_heat was SubmittedBy_Heat (0.33 conf)
submitted_gas was SubmittedBy_Gas (0.43 conf)
submitted_electric was SubmittedBy_Electric (0.41 conf)
submitted_food was SubmittedBy_Food (0.38 conf)
submitted_clothing was SubmittedBy_Clothing (0.51 conf)
submitted_expenses__1 was SubmittedBy_OtherExpenses1 (0.45 conf)
submitted_expenses__2 was SubmittedBy_OtherExpenses2 (0.45 conf)
submitted_expenses__3 was SubmittedBy_OtherExpenses3 (0.45 conf)
submitted_total_expenses was SubmittedBy_TotalExpenses (0.39 conf)
net_income_expenses was SubmittedBy_NetIncome-Expenses (0.40 conf)
submitted_dependants was SubmittedBy_Dependants (0.34 conf)
submitted_pay_ability__1 was SubmittedBy_PayAbility1 (0.45 conf)
submitted_pay_ability__2 was SubmittedBy_PayAbility2 (0.45 conf)
submitted_pay_ability__3 was SubmittedBy_PayAbility3 (0.45 conf)
submitted_pay_ability__4 was SubmittedBy_PayAbility4 (0.45 conf)
submitted_name was SubmittedBy_Name (0.42 conf)
submitted_address__1 was SubmittedBy_1Address (0.38 conf)
submitted_address__2 was SubmittedBy_2Address (0.38 conf)
submitted_telephone was SubmittedBy_Telephone (0.42 conf)
submitted_date was SubmittedBy_Date (0.43 conf)

We've done our best to group similar variables togther to avoid overwhelming the user.

Suggested Screen 0:

submitted_unemployed_time
submitted_unemployed_reason
submitted_social_security

Suggested Screen 1:

submitted_disabilities

Suggested Screen 2:

submitted_gross_pay
submitted_net_pay
submitted_net_pay_amount
pension_retirement_amount
submitted_amount_balance
submitted_savings_amount
submitted_net_income
net_income_expenses
submitted_date

Suggested Screen 3:

unemployment_disability_workers

Suggested Screen 4:

public_assistance_amount

Suggested Screen 5:

support_amount_weekly
support_amount_monthly

Suggested Screen 6:

submitted_employer_info
previous_employer_name
submitted_previous_position
submitted_previous_yr_gross_annual_income
submitted_income_amount__1
submitted_income_source
submitted_pi_tpayment_amount
submitted_checking_amount
submitted_gross_income
submitted_health_insurance
submitted_income_amount__2
submitted_income_amount__3
submitted_income_amount__4
submitted_income_amount__5
submitted_total_deductions
submitted_total_expenses
submitted_pay_ability__1
submitted_pay_ability__2
submitted_pay_ability__3
submitted_pay_ability__4

Suggested Screen 7:

text__1
text__2
text__3
text__4
text__5

Suggested Screen 8:

submitted_car
submitted_car_year_make
submitted_car_market_value

Suggested Screen 9:

submitted_financial_statement__1
submitted_financial_statement__2
bank_name__1
bank_name__2
submitted_assets__1
submitted_assets__2
submitted_assets__3
submitted_assets__4
submitted_electric
submitted_address__1
submitted_address__2

Suggested Screen 10:

submitted_liabilities__1
submitted_liabilities__2
submitted_liabilities__3
submitted_liabilities__4
submitted_pension
submitted_expenses__1
submitted_expenses__2
submitted_expenses__3

Suggested Screen 11:

submitted_federal_tax
submitted_state_tax

Suggested Screen 12:

rent_rate

Suggested Screen 13:

submitted_heat

Suggested Screen 14:

submitted_gas

Suggested Screen 15:

submitted_food

Suggested Screen 16:

submitted_clothing

Suggested Screen 17:

submitted_dependants

Suggested Screen 18:

submitted_name_address
submitted_name

Suggested Screen 19:

submitted_telephone

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Financial Statement - Housing Court

About This Form:

Identified Data Fields:

Create an Interactive Version of this Form:

The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02