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_________________ Division
Docket No. ____________________
Commonwealth of Massachusetts
The Trial Court
Juvenile Court Department
Financial Statement
(Long Form)
__________________________________ V
Plaintiff/Petitioner
___________________________________
Defendant/Petitioner
INSTRUCTIONS: This financial statement should be completed if your income equals or exceeds $75,000.00
or if ordered by the court. All item s on both sides of this form must be addressed either w ith the appropriate
amount or the w ord “none” inserted for items that are not applicable to your personal situation. Additional
sheets m ay be attached to supplement any item. You must complete and attach Schedule A if you are self-
employed or have other business income, and/or Schedule B if you ow n rental property.
I.
PERSONAL INFORMATION
Your Name ________________________________Social Security No. _______________________
Address _________________________________________________________________________
Telephone Number (_______) _________________ Date of Birth_________________Age________
Occupation_______________________________________________________________________
Employer_________________________________Employer’s Telephone No.(_____)____________
Employer’s Address________________________________________________________________
Do you have health insurance coverage?
provider _________________________________________________________________________
Do you have any natural, adopted, stepchildren, foster children or children of partners who are living
in your household half time or more? (cid:57) Yes (cid:57) No If yes, how many children? ________
(cid:57) Yes (cid:57) No If yes, name of health insurance
II.
GROSS WEEKLY INCOME/RECEIPTS FROM ALL SOURCES (strike inapplicable words)
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
l)
Self employment (attach a completed Schedule A)
Base pay salary wages
Overtime
Part time job
Tips
Commissions/Bonuses
Dividends/Interests
Income from trusts and annuities
Pension and retirement funds
Social Security
Disability unemployment or workers compensation
Public Assistance
$
$
SUBTOTAL
JV-34 (06/07)
Page 2 Financial Statement (Long Form) Docket No. ____________________
SUBTOTAL from Page 1
m)
Child Support/Alimony (actually received)
Rental Income (attach completed Schedule 5)
Royalties and other rights
Contributions from household member(s)
Other (specify)
TOTAL GROSS W EEKLY INCOME/RECEIPTS
III.
WEEKLY DEDUCTIONS FROM GROSS INCOME
Tax W ithholding
Federal tax withholding/estimated payments
Number of withholding allowances claimed ______
State tax withholding/estimated payments
Number of withholding allowances claimed ______
$
$
$
$
n)
o)
p)
q)
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
l)
n)
o)
p)
q)
r)
Other Deductions
FICA
Medicare
Medical Insurance
Union Dues
Child Support
Spousal Support
Retirement
Savings
Deferred Compensation
Credit Union (Loan)
m)
Credit Union (Savings)
Charitable Contributions
Life Insurance
Other (specify)
Other (specify)
Other (specify)
TOTAL WEEKLY DEDUCTIONS FROM PAY (add a-r)
$
Page 3 Financial Statement (Long Form)
Docket No. __________________
IV.
NET WEEKLY INCOME
a)
b)
Enter total gross weekly income/receipts (See I)
Enter total weekly deductions from pay
NET WEEKLY INCOME (Subtract IV(b) from IV(a))
V.
VI.
GROSS INCOME FROM PRIOR YEAR
(attach copy of W-2 and 1099 forms for prior year and Schedule A, if self-employed.)
Number of years you have paid into Social Security _________
COUNSEL FEES
Anticipated range of total legal exposure to prosecute this action ___________to___________
Retainer amount(s) paid to your attorney(s)
Legal fees incurred against the retainer(s)
VII.
WEEKLY EXPENSES NOT DEDUCTED FROM NET INCOME
INSTRUCTIONS. All expense figures must be listed by their WEEKLY total. DO NOT list expenses
by their MONTHLY total. In order to compute the w eekly expense, divide the monthly expense by
4.3. For example, if your rent is $500 per m oth, divide 500 by 4.3. This w ill give you a w eekly
expense of $116.28. Do not duplicate w eekly expenses Strike inapplicable term s.
Rent
Mortgage (P&I Taxes Insurance if escrowed)
Property Taxes and assessments
Homeowners Insurance
Tenants Insurance
Maintenance Fees/Condominium Fees
Maintenance/Repairs
Heat (type _______________________)
Electricity
Propane/Natural Gas
Telephone
W ater/Sewer
Food
House Supplies
Laundry
Dry Cleaning
SUBTOTAL
$
$
$
$
$
Page 4 Financial Statement (Long Form)
Docket No. __________________
SUBTOTAL FROM PAGE 3
$
Clothing
Life Insurance
Medical Insurance
Uninsured medical dental expenses
Incidentals/toiletries
Motor vehicle expenses
Fuel
Insurance
Maintenance
Loan payment(s)
Entertainment
Vacation
Cable Television
Child Support (attach a copy of the court order)
Child(ren)’s Day Care Expense
Child(ren)’s Education
Education (self)
Employment related expenses (non-reimbursable)
Uniforms
Travel
Required continuing education
Other (specify) __________________________________
Charitable Contributions/Church Giving
Child(ren)’s allowance
Extraordinary travel expenses for visitation with child(ren)
Other (specify) ____________________________________
Other (specify) ____________________________________
Other (specify) ____________________________________
TOTAL WEEKLY EXPENSES NOT DEDUCTED FROM PAY
$
Page 5 Financial Statement (Long Form)
Docket No. __________________
VIII.
ASSETS
INSTRUCTIONS. List all assets including, but not limited to the follow ing. If additional space is
needed for any answ er or to disclose additional assets, an attached sheet may be filed.
A.
Real Estate: Primary Residence Year of Purchase _________
Address ____________________________________________________________
Title held by_________________________________________________________
st
nd
st
nd
Outstanding 1 Mortgage
Outstanding 2 Mortgage or home equity loan
Equity
Purchase Price of Property
Current Assessed Value of Property
(Date of last assessment: ______________________)
Fair Market Value of Property
Outstanding 1 Mortgage
Outstanding 2 Mortgage or home equity loan
Equity
Purchase Price of Property
Current Assessed Value of Property
(Date of last assessment: ______________________)
Fair Market Value of Property
B.
Real Estate: Vacation or Second Hom e Year of Purchase _________
Address ____________________________________________________________
Title held by_________________________________________________________
C.
Motor Vehicles: cars, trucks, motorcycles, boats, recreational vehicles, aircraft,
farm machinery, etc.
Type________________Make__________________Model_______________________
Type________________Make__________________Model_______________________
$
$
$
$
Purchase Price
Fair Market Value
Outstanding Loan
Equity
Purchase Price
Fair Market Value
Outstanding Loan
Equity
Page 6 Financial Statement (Long Form)
Docket No. __________________
Institution
Account
Number
Listed
Beneficiary
Current
Balance/Value
E.
Other Assets. List assets w hich 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 particulars as
indicated, e.g. institution/plan name(s), account number(s), named beneficiaries and
current balances, if applicable.)
Institution
Account
Num ber
Listed
Beneficiary
Current
Balance/Value
$
$
D.
Pensions
Defined Benefit Plan
Defined Contribution Plan
Checking Account(s)
Savings Account(s)
Cash on Hand
Certificate(s) of Deposit
Credit Union
Account(s)
Funds Held in Escrow
Stocks
Bonds
Bond Fund(s)
Notes Held
Cash in Brokerage
Account(s)
Money Market
Account(s)
U.S. Savings Bonds
IRAs
Keough
Profit Sharing
Page 7 Financial Statement (Long Form)
Docket No. __________________
Institution
Account
Num ber
Listed
Beneficiary
Current
Balance
$
Deferred
Compensation
Other Retirement Plans
Annuity (specify
whether tax deferred or
tax shelter)
Life Insurance Cash
Value (specify term or
whole)
Judgments/Liens
Pending Legacies
and/or inheritances
Jewelry
Contents of Safe or
Safe Deposit Boxes
Firearms
Collections
Tools/Equipment
Crops/Livestock
Home Furnishings
Art and Antiques
Other (specify)
Other (specify)
Other (specify)
Page 8 Financial Statement (Long Form)
Docket No. _________________
IX.
Liabilities (List loans, credit card, consumer, installment debt, etc. w hich are not listed elsew here.
INSTRUCTIONS. All payment figures must be listed by their WEEKLY amount. DO NOT list
paym ents by their MONTHLY amount. In order to compute the w eekly expense, divide the monthly
expense by 4.3. For example, if your rent is $500 per moth, divide 500 by 4.3. This w ill give you a
w eekly expense of $116.28.
CREDITOR
KIND OF DEBT
DATE INCURRED
AMOUNT DUE
W EEKLY
PAYMENT
$
$
TOTALS
$
$
Page 9 Financial Statement (Long Form)
Docket No. ________________
CERTIFICATION BY AFFIANT
I certify under the penalties of perjury that the information stated on this Financial Statement
and the attached Schedules if any is complete, true and accurate. I UNDERSTAND THAT
MISREPRESENTATION OF ANY OF THE INFORMATION PROVIDED WILL SUBJECT ME TO
SANCTIONS AND MAY RESULT IN CRIMINAL CHARGES BEING FILED AGAINST ME.
______________________________
_____________________________________
Date
Signature
COMMONW EALTH OF MASSACHUSETTS
County of ________________________
Then personally appeared the above ____________________________ and declared the
foregoing to be true and correct before me this ___________ day of __________________20___.
____________________________________
Notary Public
INSTRUCTIONS: In any case where an attorney is appearing as a party, said attorney MUST
complete the Statement by Attorney.
STATEMENT BY ATTORNEY
I the undersigned attorney am admitted to practice law in the Commonwealth of Massachusetts - am
admitted pro hoc 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.
______________________________
_____________________________________
Date
Signature
Name of Attorney (print) ___________________________________________________________
Address: _______________________________________________________________________
Telephone No. (_____)________________________
BBO # _____________________________________
