Here is the text we could read:
ETADKONT FINANSYE
MOUN KI DWE PEYE LAJAN
DAPRE JIJMAN
NIMEWO REJIS
FÒM SA A SE PA POU SOUMÈT
NAN TRIBINAL. SE POU
ENFÒMASYON SÈLMAN.
Tribinal Premye Enstans
Massachusetts
Sesyon pou Ti Reklamasyon
NON KI SOU DOSYE
SE POU REZON ENFÒMASYON SÈLMAN.
NON MOUN KI DWE PEYE LAJAN DAPRE JIJMAN (moun ki te pèdi pwosè a epi ki dwe lajan an)
(cid:2)(cid:3)Divizyon________ TRIBINAL MINISIPAL BOSTON
(cid:2)(cid:3)Divizyon ________ TRIBINAL DISTRI
(cid:2)(cid:3)Divizyon ________ TRIBINAL LOJMAN
ADRÈS KAY
NIMEWO SEKIRITE SOSYAL
NIMEWO LISANS CHOFÈ AK ETA KI BAY LISANS LAN
MOUN K
TIMOUN K
KANTITE AK LAJ TIMOUN K AP VIV AVÈK OU
DEPDEP
DEPI KONBYEN TAN OU NAN
TRAVAY LA?
Y LA?
VAY LA?
T
T
BYEN
.....
...............................................
......
..
................................................
NIMEWO TELEFÒN KAY
DAT NESANS
LÒT
VIV AV
ETA SIVIL
Adrès:
t
ou Prè
sou Prè
yetè (yo
yetè (yo)
TE OTE O
KAY KOTE OU RETE
Lòt Pwopriyetè (yo):
BYEN YO (bay valè tout byen yo)
ut byen yo
Balans sou Prè Ipotekè: $ ..................
swa
Byen imobilye ou posede oswa
ou posede avèk lòt moun
court.
la. P VIV AVÈ
coc
ibunalalONBYEN T
c
c
c
the
bun
ibun
(bay valhe
thehe
bu
to swa
r
t
t
nan nKO
sub mit
i
l
re m èt poteot
not MM
D o Veyey
P ae/Mak a
D
only.
nly
y
y
referans. An
an
ra
pou . pa spa
Veyikil (yo)/Bato (yo) Ou Posede VEYIKIL/BATO 1
Ranbousman Taks Ou
Espere Resevwa:
K
Kantite lajan ou Dwe sou li: $ ...................
K
Revni nan Lokasyon:
evni na
Revni na
A
Ane/Mak ak Modèl:
A
Labank/Koperativ:
Ane ou Achte li:
Valè Machann:
n:
Kont Labank yo
Pri or
Pri ou Achte li:
Nimewo Kont:
$ ..................
$ ..................
$ ..................
Lokasyo
Lokasyo
Balans:
AN CHÈK
e/Mak a
ato (yo
Bato (yo)
e o
e ou
achaacha
kil (y
kil (y
kè:kè:
EPAY
................................................
................................................
$ ....................... $ ..................
................................................
................................................
$ ..................
$ ..................
$ ..................
VEYIKIL/BATO 2
$ ..................
$ ..................
$ ...............................................
METYE
NON AK ADRÈS KONPAYI KOTE W AP TRAVAY
REVNI (bay tout sous revni ou)
Peman Ou anvan Dediksyon:
$ ................ pa semèn
Peman Ou apre Dediksyon:
$ ................ pa semèn
Peman Madanm/Mari Ou apre Dediksyon: $ ................ pa semèn
Revni nan Sipò Timoun:
Pansyon:
AFDC/SSI:
$ ................ pa semèn
$ ................ pa semèn
$ ................ pa semèn
Lòt (bay detay padèyè fòm nan):
$ ................ pa semèn
Revni Total pa Semèn:
$ ................ pa semèn
Pansyon alimantè/Sipò Timoun:
$ ................ pa semèn
.....
$ ......
$
DEPANS
n
$ ................ pa semèn
sem
semè
emènmèn
$ ................ pa semèn
......... papa
$ ................ pa semèn
a semèn
a semèn
........
............
for reference papa
a aaala sèlm an $ .........
sevizyon
i
evizyon
......
$ ................ pa semèn
....... pa
........
$
$
$ ................ pa semèn
$ ................ pa semèn
$ ......
$
Lwaye/Prè Ipotekè
Sèvis piblik:
Manje:
Gadri:
Sèvis Transpò
Asirans:
s
i
T hishisformel
T his
sasa
a
s
F ò m m
Amizman (ak sèvis kab televizyon tou):
ou): u):
$ ................ pa semèn
$
$
Lòt (bay detay padèyè fòm nan):
fòm na
yè fòm na
$ ................ pa semèn
Semèn:
Revni Total pa Semèn:
Semèn:
$ ................ pa semèn
Konbyen lajan ou genyen an kach? $ .......................................
Èske ou te fè kado oswa transfere nenpòt byen depi reklamasyon sa
a te fèt la? (Si se wi, bay eksplikasyon padèyè.) (cid:2) Non (cid:2) Wi
(Bay padèyè fòm nan nenpòt sa ki gen valè ki pa endike anwo a ou
posede oswa ou posede avèk lòt moun, oswa yon lòt moun pou ou.)
KREYANSYE
REYAREYA
KALITE DÈT
DAT ORIJIN
SA OU DWE PEYE ANTOU
PEMAN PA SEMÈN
1 ..................................................................................................................................... $ ............................... $ .........................
..........
..........
DÈT (bay tout dèt ki pa endike anwo a nan depans ou yo – pa egzanp, dèt kat kredi)
2 ..................................................................................................................................... $ ............................... $ .........................
....
........
3 ..................................................................................................................................... $ ............................... $ ........................
Anba sanksyon pou fo temwayaj, mwen sèmante enfòmasyon ki anwo a se enfòmasyon ki konplè ak egzat dapre tout sa mwen konnen.
DAT SIYATI A
SIYATI MOUN KI DWE LAJAN DAPRE JIJMAN AN
X
Dapre Règ 9(c), Ti Reklamasyon Inifòm, tout enfòmasyon ki nan deklarasyon sou sèman sa a se enfòmasyon ki KONFIDANSYÈL.
Li dwe disponib pou nenpòt lòt moun ki nan konfli sa a, men li pa dwe disponib pou piblik la enspekte, sof si Tribinal la egzije sa.
Financial Statement Haitian Creole 08/2012 www.mass.gov/courts/forms
This document was developed under Grant No. 11-T-162 of the State Justice Institute. The form does not necessarily represent the official position or policies of the State Justice Institute.
$_____________
$
Sa a se kantite lajan salè anvan
dediksyon ou pa semèn ki egzonere
nan nenpòt lòt peman.
REVNI KI EGZONERE NAN LÒD POU PEMAN YO
. TOUT REVNI NAN SOUS KI ANBA LA YO egzonere dapre lalwa nan nenpòt lòd pou peman:
1
3[d][1
3[d][1
.S.C. §
U.S.C. §
the court.
ibunal 383 la.
to
nan
sub mit.S.C. §
i
l
re m èt G.L. c.
notman ak
P a
r
t
MAN R
MAN R
1
(42 U.S
t (42 U.S
FDC) (
AFDC) (
G.L. c.
S.C. §
an ak
18118
P
1
D o
(cid:114)(cid:1) Lòt Avantaj Asirans pou Andikap ki rive jiska $400 pa semèn (G.L. c. 175, § 110A)
(cid:114)(cid:1) Èd Annijans pou Granmoun Aje ak Moun ki Andikape (kounye a G.L. c. 117A)
(cid:114)(cid:1) Avantaj pou Veteran
Avantaj Federal pou Veteran (38 U.S.C. § 5301[a])
Avantaj Espesyal pou Sèten Veteran Dezyèm Gè Mondyal (42 U.S.C. § 1001)
)
)
Avantaj Meday Lonè pou Veteran (38 U.S.C. § 1562)
Avantaj pou Veteran Eta (G.L. c. 115, § 5)
(cid:114)(cid:1) Avantaj Èd Pwovizwa pou Fanmi ki gen Timoun Depandan (AFDC) (G.L. c. 118, §10)
(cid:114)(cid:1) Avantaj Sibvansyon Jeneral nan Sèvis Sante pou Manman ak Pitit (42 U.S.C. § 701)
(cid:114)(cid:1) Lòt avantaj asistans piblik (G.L. c. 235, § 34, kenz)
(cid:114)(cid:1) Avantaj Asirans Federal pou Granmoun Aje, Sivivan, ak Moun ki Andikape (42 U.S.C. § 407)
7)
(cid:114)(cid:1) Revni Sekirite Anplis (SSI) pou Granmoun Aje, Moun ki Avèg ak Moun ki Andikape (42 U.S.C. § 1383[d][1])
2. Answit, YON PÒSYON NAN SALÈ OSWA NAN PEMAN RETRÈT KI BAZE SOU TRAVAY
egzonere dapre lalwa nan nenpòt lòd pou peman. Kantite lajan ki egzonere a se
$400 oswa 85% salè pa semèn ou anvan dediksyon, kèlkeswa sa ki pi gran an.
(cid:114)(cid:1) Avantaj pou Chomaj (G.L. c. 151A, § 36)
(cid:114)(cid:1) Avantaj Konpansasyon Travayè (G.L. c. 152, § 47)
(cid:114)(cid:1) Avantaj Sekirite Sosyal (42 U.S.C. § 401)
Lalwa Massachusetts egzonere kantite lajan ki pi gwo nan 85% salè anvan dediksyon moun ki dwe lajan an oswa 50 fwa pi gwo nan salè minimòm
federal la ($7.25 depi 24 jiyè 2009, oswa salè minimòm Massachusetts ($8.00 pou chak G.L.c. 151, § 1) pou chak semèn oswa pòsyon ladan.
(G.L. c. 224, § 16 & c. 246, § 28). Egzonerasyon federal (15 U.S.C. § §1671-1677) pa anvigè paske l ap toujou pi piti pase egzonerasyon Massachusetts.
. Ka
AN P
AN PE
nvan
anvan
dediks
dediks
u pem
ou pema
85% salè a
% salè
ssachu
Massachus
5 U.S.CU.S.C
gwo n
pi gwo na
minimòm
è minimòm
yon fede
asyon feder
only. NA
ou referans. an. Kan
ference u a
ou
pou
refe
efe
s for ÈY TRY T
sèlm anAY AKIAK
i
forman “n “salsa
la
a
T hisanva
sa te late l
F ò m u anvanv
alè anva
alè anva
antre 85% salè anvan dediksyon ou pa semèn ➞
antra
antre kantite lajan salè anvan dediksyon ou pa semèn ➞
antre k
antre k
Si salè anvan dediksyon ou pa semèn pi piti pase $400,
Si salè anvan dediksyon ou pa semèn pi piti pase $470,
Si salè ou anvan dediksyon pa semèn se $400–$470, antre $400 ➞
Ekri kantite lajan “salè anvan dediksyon ou pa semèn” la a =
van de
nvan de
ksyoksyo
ajanjan
LÈ O
SALÈ OS
salè o
salè o
an de
an de
RAVRA
ZEZE
anan
n
n
FÈY TRAVAY AKIZE A POU KALKIL KANTITE LAJAN KI EGZONERE
NANNAN
NAN SALÈ OSWA NAN PEMAN RETRÈT KI BAZE SOU TRAVAY
Financial Statement Haitian Creole 08/2012 www.mass.gov/courts/forms
This document was developed under Grant No. 11-T-162 of the State Justice Institute. The form does not necessarily represent the official position or policies of the State Justice Institute.
0000050833-Binder 049 Haitian...t-of-judgment-debtor-1_HC.pdf
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): 5
- Average fields per page: 2
- Reading Level: Grade 5
- LIST Grouping(s):
Unknown
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.
tribinal_minisipal_boston was tribinal_minisipal_boston (0.54 conf)page_field was page_0_field_1 (0.31 conf)tribinal_distri was tribinal_distri (0.35 conf)bay_tout_ki_pa_nan_ou was dèt__bay_tout_dèt_ki_pa_endike_anwo_a_nan_depans_ou_yo_pa_egzanp__dèt_kat_kredi (0.48 conf)af_f was AFF004 (0.51 conf)
We've done our best to group similar variables togther to avoid overwhelming the user.
Suggested Screen 0:
tribinal_minisipal_bostonpage_fieldtribinal_distribay_tout_ki_pa_nan_ou
Suggested Screen 1:
Create an Interactive Version of this Form:
The Weaver creates a draft guided interview from a template form, like the one provided here. You can use the link below to open this form in the Weaver.
To learn more, read "Weaving" your form into a draft interview.
Launch Form in Weaver
