Here is the text we could read:
Commonwealth of Massachusetts
The Trial Court
Juvenile Court Department
_________________ Division
Docket No. _______________
FINANCIAL STATEMENT
(SHORT FORM)
____________________________________________ v ___________________________________________
Plaintiff
Defendant
Instructions: If your income equals or exceeds $75,000.00 you must complete the LONG FORM financial statement, unless
otherwise ordered by the Court. All questions on both sides of this form must be answered in full or the word “none” inserted.
If additional space is needed for any answer, an attached sheet may be filed in addition to, but not in lieu of, the answer.
1.
Gross Weekly Income
a)
b)
c)
d)
e)
f)
h)
i)
j)
k)
a)
b)
c)
d)
e)
a)
b)
c)
d)
e)
f)
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Base pay from salary, wages
Self Employment Income (attach a completed Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . .
Income from overtime-commissions-tips-bonuses-part-time job . . . . . . . . . . . . . . . . . . . . . . .
Dividends - Interest
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Income from trusts or annuities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pensions and retirement funds
Disability, unemployment insurance or worker’s compensation
. . . . . . . . . . . . . . . . . . . . . . .
Public Assistance (welfare, A.F.D.C. payments) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . .
Rental from Income Producing Property (attach a completed Schedule B)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
All other sources (including child support, alimony)
l) Total Gross Weekly Income (a through k)
2.
Itemize Deductions from Gross Income
Federal income tax deductions (claiming _________ exemptions)
State income tax deductions (claiming _________ exemptions)
F.I.C.A./Medicare
Medical Insurance
Union Dues
. . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
f) Total Deductions (a through e)
3.
4.
5.
6.
Adjusted Net Weekly Income
2(I) minus 2(f)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
Other Deductions from Salary
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Credit Union (Loan Repayment or Savings)
Savings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Retirement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other - Specify (such as Deferred Compensation or 401(K)__________________________
a)
b)
c)
d)
e) Total Deductions (a through d)
Net Weekly Income
3 minus 4(e) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gross Yearly Income Prior Year
(attach copy of all W-2 and 1099 forms per prior year)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
7.
W eekly Expenses (Do Not Duplicate W eekly Expenses - Strike Inapplicable W ords)
Rent-Mortgage (PIT)
$ _________
W ater/Sewer
Homeowner/Tenant Insurance
$ _________
Food
Maintenance and Repair
$ _________
Uninsured Medicals
Heat (Type________)
$ _________
House Supplies
$__________
$ _________
$ _________
$ _________
Electricity and/or Gas
$ _________
Laundry and Cleaning
$ _________
Telephone
$ _________
Clothing
$ _________
g)
h)
i)
j)
k)
l)
JV-33 (06/07) (over)
n)
o)
p)
a)
b)
c)
a)
b)
c)
d)
e)
f)
g)
a)
b)
c)
d)
8.
9.
m)
Life Insurance
$ _________
Motor Vehicle Loan
Medical Insurance
$ _________
Child Care
Incidentals and Toiletries
$ _________
Other (specify)
q)
r)
s)
$ _________
$ _________
$ _________
Motor Vehicle Expenses
$ _________
________________________________
$ _________
Total W eekly (a through s)
$ _________
Counsel Fees
Retainer amount(s) paid to your attorney(s)
Legal Fees incurred to date, against retainer(s)
Anticipated range of total legal expenses to prosecute action $ ______ to $ ________
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________
$ ________
Assets (Attach additional schedule for additional real estate and other assets, if necessary)
Real Estate
Location ___________________________________________________________________
Title held by ________________________________________________________________
Fair market value $ _______________ - Mortgage $ _________________ = Equity
IRA, Keogh, Pension, Profit Sharing, Other Retirement Plans ______________________
__________________________________________________________________________
__________________________________________________________________________
Tax Deferred Annuity Plan(s) _________________________________________________
Life Insurance: Present Cash Value ___________________________________________
Savings & Checking Accounts, Money Market Accounts and CDs - which are held
individually, jointly, in the name of another person for your benefit, or held by you for the
benefit of your minor child(ren). List Financial Institution Name and Account Numbers
_________________________________________________________________________
_________________________________________________________________________
Motor Vehicles
Fair Market Value $________________ Motor Vehicle Loan $_____________ = Equity
Fair Market Value $________________ Motor Vehicle Loan $_____________ = Equity
Other (such as - stocks, bonds, collections)____________________________________
_________________________________________________________________________
_________________________________________________________________________
h) Total Assets (a through g)
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
$ _________
11.
Liabilities: Creditor
Date of Origin
Amount Due
W eekly Payment
Nature of
Debt
$
$
$
$
Total Amount Due and Total Weekly Paym ent
12.
Number of Years you have paid Social Security __________ years
I certify under the penalties of perjury that my income and expenses, assets, and liabilities as stated herein are true to the best
of my knowledge and belief. I have carefully read this financial statement and I certify the information is true and complete.
Signature _______________________________________________________ Date ____________________________
STATEMENT OF ATTORNEY
I, the undersigned attorney, am admitted to practice law in the Commonwealth of Massachusetts - am admitted pro hac vice for
the purposes of this case – and am an officer of the court. As the attorney for the party on whose behalf this Financial Statement
is submitted, I hereby state to the court that I have no knowledge that any of the information contained herein is false.
Attorney’s Signature_______________________________________________ Date ____________________________
Address _________________________________________________________ Telephone No.(_____)______________
B.B.O. No. _____________________________________________
WRITE “NONE” ON ANY LINE THAT DOES NOT APPLY TO YOU.
DO NOT LEAVE ANY LINES BLANK
Financial Statement - Short Form
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): 24
- Average fields per page: 12
- Reading Level: Grade 9
- LIST Grouping(s):
Unknown
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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.
total_w_eekly was total_w_eekly__a_through_s (0.57 conf)mortgage was mortgage (0.41 conf)page_field__1 was page_1_field_2 (0.36 conf)fair_market_value was fair_market_value (0.37 conf)pension_profit_retirement_plans was ira__keogh__pension__profit_sharing__other_retirement_plans (0.45 conf)page_field__2 was page_1_field_5 (0.36 conf)page_field__3 was page_1_field_6 (0.36 conf)page_field__4 was page_1_field_7 (0.36 conf)equity was equity (0.47 conf)page_field__5 was page_1_field_9 (0.36 conf)page_field__6 was page_1_field_10 (0.36 conf)page_field__7 was page_1_field_11 (0.36 conf)page_field__8 was page_1_field_12 (0.36 conf)tax_deferred_annuity_plan was tax_deferred_annuity_plan_s (0.41 conf)minor_financial_institution was benefit_of_your_minor_child_ren_list_financial_institution_name_and_account_numbers (0.39 conf)page_field__9 was page_1_field_15 (0.36 conf)page_field__10 was page_1_field_16 (0.36 conf)motor_vehicles was motor_vehicles (0.41 conf)motor_vehicle_loan was motor_vehicle_loan (0.34 conf)page_field__11 was page_1_field_19 (0.36 conf)stocks_bonds_collections was other__such_as_stocks__bonds__collections (0.43 conf)h_total_assets_g was h__total_assets__a_through_g (0.36 conf)page_field__12 was page_1_field_22 (0.36 conf)b was b_b_o__no (0.34 conf)
We've done our best to group similar variables togther to avoid overwhelming the user.
Suggested Screen 0:
total_w_eeklymortgagepage_field__1fair_market_valuepension_profit_retirement_planspage_field__2page_field__3page_field__4equitypage_field__5page_field__6page_field__7page_field__8tax_deferred_annuity_planminor_financial_institutionpage_field__9page_field__10motor_vehiclesmotor_vehicle_loanpage_field__11stocks_bonds_collectionsh_total_assets_gpage_field__12b
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