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The Massachusetts Short Financial Statement form is an essential document used in various legal proceedings, particularly within the Probate and Family Court. This form is designed for individuals whose annual income is less than $75,000, allowing them to provide a concise overview of their financial situation. It includes sections for personal information, gross weekly income from all sources, itemized deductions, and net income calculations. Additionally, the form requires a detailed account of weekly expenses, assets, and liabilities, ensuring that all financial aspects are thoroughly documented. By completing this form, individuals can present their financial circumstances clearly, which is crucial for matters such as child support, alimony, and other financial obligations. The process involves not only listing income and expenses but also certifying the accuracy of the information provided, underscoring the importance of honesty and transparency in legal matters. The Short Financial Statement serves as a vital tool for both the court and the parties involved, facilitating fair and informed decisions based on a complete financial picture.

Massachusetts Short Financial Statement Example

 

 

Commonwealth of Massachusetts

 

Division

 

The Trial Court

Docket No.

 

Probate and Family Court Department

 

FINANCIAL STATEMENT

(Short Form)

INSTRUCTIONS: if your income equals or exceeds $75,000.00 annually, you must complete the LONG FORM financial statement, unless otherwise ordered by the court.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Plaintiff/Petitioner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Defendant/Petitioner

 

 

 

 

 

 

1. PERSONAL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security No.

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Street address)

 

 

 

 

 

 

 

 

 

 

 

(City/Town)

 

 

(State)

 

 

(Zip)

 

 

 

 

Tel. No.

 

 

 

 

Date of Birth

 

 

 

 

No. of children living with you

 

 

 

 

 

Occupation

 

 

 

 

 

 

 

 

 

 

 

Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer's Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Street address)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(City/Town)

(State)

 

(Zip)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tel. No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

j) Social Security

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

k)

Disability

Unemployment insurance

Worker's compensation

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

l) Public Assistance (e.g. welfare, TAFDC, SNAP) (not included in gross income for child support)

 

 

 

 

 

 

 

 

 

 

 

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 9/15/17

Page 1 of 4

C.G.F.

 

 

 

 

Commonwealth of Massachusetts

 

 

 

 

 

 

 

 

Division

 

The Trial Court

Docket No.

 

 

 

 

Probate and Family Court Department

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FINANCIAL STATEMENT

 

 

 

 

 

 

 

 

 

 

 

 

(Short Form)

 

 

 

 

 

 

 

3.

ITEMIZED DEDUCTIONS FROM GROSS INCOME

 

 

 

 

 

 

 

 

a) Federal income tax deductions (claiming

 

 

exemptions)

$

 

 

 

 

 

 

b) State income tax deductions (claiming

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

exemptions)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

$

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

b) Savings

 

 

 

 

 

 

 

 

 

 

 

 

c) Retirement

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d) Other-Specify (i.e. Child Support, Deferred Compensation or 401K)

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e) Total Deductions (a through d)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a) Rent or Mortage (PIT)

$

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

$

l) Life Insurance

$

m) Medical 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 $

 

 

CJ-D 301 S 9/15/17

Page 2 of 4

C.G.F.

Division

 

Commonwealth of Massachusetts

Docket No.

 

The Trial Court

 

 

Probate and Family Court Department

 

 

 

 

 

 

FINANCIAL STATEMENT

 

 

 

(Short Form)

 

10.ASSETS (attach additional sheet if necessary)

a) Real Estate

 

 

 

 

 

 

 

Location

 

 

 

 

 

 

 

 

Title held in the name of

 

 

 

 

 

 

 

 

Fair Market Value $

 

 

- Mortgage $

 

 

 

 

= Equity $

b) Motor Vehicles

 

 

 

 

 

 

 

Fair Market Value $

 

 

- Motor Vehicle Loan $

 

 

 

= Equity $

Fair Market Value $

 

 

- Motor Vehicle Loan $

 

 

 

= Equity $

c)IRA, Keogh, Pension, Profit Sharing, Other Retirement Plans: Financial Institution or Plan Name and Account Number

$

$

$

d) Tax Deferred Annuity Plan(s)

$

e) Life Insurance: Present Cash Value

$

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):

Financial Institution or Plan Name and Account Number

$

$

$

g) Other (e.g. stocks, bonds, collections)

$

$

h) Total Assets (a through g)

$

11.LIABILITIES (Do not list expenses shown in item 8 above.)

a)

b)

c)

d)

Creditor

Nature of Debt

Date Incurred

Amount Due

Weekly Payment

$$

$$

$$

$$

e) Total Liabilities

$

$

CJ-D 301 S 9/15/17

Page 3 of 4

C.G.F.

 

 

Commonwealth of Massachusetts

 

Division

 

The Trial Court

Docket No.

 

Probate and Family Court Department

 

 

 

 

 

FINANCIAL STATEMENT

 

 

 

(Short Form)

 

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.

Date

 

Signature

INSTRUCTIONS: In any case where an attorney is appearing for 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 of attorney)

(Print name)

(Street address)

(City/Town)

(State)

(Zip)

Tel. No.

B.B.O. #

CJ-D 301 S 9/15/17

Page 4 of 4

C.G.F.

Form Specs

Fact Name Detail
Governing Law The Massachusetts Short Financial Statement is governed by Massachusetts General Laws, Chapter 208, Section 23.
Income Threshold Individuals with an annual income of $75,000 or more must complete the Long Form financial statement unless the court orders otherwise.
Certification Requirement The form requires certification under penalties of perjury, affirming that the information provided is complete and accurate.
Weekly Income Calculation The form includes a section for calculating total gross weekly income from various sources, ensuring comprehensive disclosure.
Please rate Fill in a Valid Massachusetts Short Financial Statement Form Form
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