Financial Statement - Short Form - Juvenile Court Page 2
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1
2m)
Life Insurance
$ _________
q)
Motor Vehicle Loan
$ _________
n)
Medical Insurance
$ _________
r)
Child Care
$ _________
o)
Incidentals and Toiletries
$ _________
s)
Other (specify)
$ _________
p)
Motor Vehicle Expenses
$ _________
________________________________
$ _________
$ _________
Total W eekly (a through s)
8.
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 expenses to prosecute action $ ______ to $ ________
9.
Assets (Attach additional schedule for additional real estate and other assets, if necessary)
a)
Real Estate
Location ___________________________________________________________________
Title held by ________________________________________________________________
$ _________
Fair market value $ _______________ - Mortgage $ _________________
= Equity
b)
$ _________
IRA, Keogh, Pension, Profit Sharing, Other Retirement Plans ______________________
$ _________
__________________________________________________________________________
$ _________
__________________________________________________________________________
c)
$ _________
Tax Deferred Annuity Plan(s) _________________________________________________
d)
$ _________
Life Insurance: Present Cash Value ___________________________________________
e)
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
$ _________
_________________________________________________________________________
$ _________
_________________________________________________________________________
f)
Motor Vehicles
$ _________
Fair Market Value $________________ Motor Vehicle Loan $_____________
= Equity
$ _________
Fair Market Value $________________ Motor Vehicle Loan $_____________
= Equity
g)
$ _________
Other (such as - stocks, bonds, collections)____________________________________
$ _________
_________________________________________________________________________
$ _________
_________________________________________________________________________
$ _________
h) Total Assets (a through g)
11.
Liabilities: Creditor
Nature of
Date of Origin
Amount Due
W eekly Payment
Debt
a)
$
$
b)
c)
d)
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
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