Financial Statement Short Form 2017-2026

00 annually you must complete the LONG FORM financial statement unless otherwise ordered by the court. Commonwealth of Massachusetts The Trial Court Probate and Family Court Department Division Docket No. FINANCIAL STATEMENT Short Form INSTRUCTIONS if your income equals or exceeds 75 000. F.D.C. payments m Child Support Alimony actually received n Rental from income producing property attach a completed Schedule B o Royalties and other rights p Contributions from household member s q Other specify r Total Gross Weekly Income/Receipts add items a-q CJ-D 301 S 7/07 Page 1 of 4 C. Plaintiff/Petitioner Defendant/Petitioner V. 1. PERSONAL INFORMATION Your Name Social Security No* Address Street address Tel* No* City/Town Date of Birth Occupation State Zip No* of children living with you Employer Employer s Address Do you have health insurance coverage Yes No if yes name of health insurance provider 2. GROSS WEEKLY INCOME/RECEIPTS FROM ALL SOURCES a Base pay from Salary Wages b Overtime c Part-time job d Self-employment attach a completed schedule A e Tips f Commissions Bonuses g Dividends Interest h Trusts Annuities i Pensions Retirement funds k Disability Unemployment insurance Worker s compensation l Public Assistance welfare A. G*F* 3. ITEMIZED DEDUCTIONS FROM GROSS INCOME a Federal income tax deductions claiming exemptions b State income tax deductions claiming c F*I. C. A. and Medicare d Medical Insurance e Union Dues f Total Deductions a through e 4. ADJUSTED NET WEEKLY INCOME 2 r minus 3 f 5. OTHER DEDUCTIONS FROM SALARY/WAGES a Credit Union Loan repayment Savings c Retirement d Other-Specify i*e* Child Support Deferred Compensation or 401K 6. NET WEEKLY INCOME 4 minus 5 e 7. GROSS YEARLY INCOME FROM PRIOR YEAR attach copy of all W-2 and 1099 forms for prior year Number of Years you have paid into Social Security 8. WEEKLY EXPENSES b Homeowners/Tenant Insurance c Maintenance and Repair d Heat e Electricity and/or Gas f Telephone g Water/Sewer h Food i House Supplies j Laundry and Cleaning k Clothing a Rent or Mortage PIT l Life Insurance n Uninsured Medicals o Incidentals and Toiletries p Motor Vehicle Expenses q Motor Vehicle Payment r Child Care s Other explain t Total Weekly Expenses a through s 9. COUNSEL FEES a Retainer amount s paid to your attorney s b Legal fees incurred to date against retainer s c Anticipated range of total legal expense to litigate this action to 10. ASSETS attach additional sheet if necessary a Real Estate Location Title held in the name of Fair Market Value Equity - Mortgage - Motor Vehicle Loan c IRA Keogh Pension Profit Sharing Other Retirement Plans Financial Institution or Plan Name and Account Number d Tax Deferred Annuity Plan s f Savings Checking Accounts Money Market Accounts Certificates of Deposit-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 g Other e*g* stocks bonds collections h Total Assets a through g 11. LIABILITIES Do not list expenses shown in item 8 above. Creditor Nature of Debt Date Incurred Amount Due Weekly Payment a b c d e Total Liabilities CERTIFICATION 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.