Financial Statement - Short Form (Standard)
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1
2Commonwealth of Massachusetts
The Trial Court
Division
Probate and Family Court Department
Docket No.
Financial Statement
(SHORT FORM)
v.
Plaintiff/Petitioner
Defendant/Petitioner
INSTRUCTIONS:
If your income equals or exceeds $75,000 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 work “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. Information contained herein is confidential and only available to the parties and
persons authorized under Probate and Family Court Department Supplemental Rule 401.
1.
Your Name
Soc. Sec. No.
Address
Age
Tel. No.
No. of Children living with you
Occupation
Employer
Employer’s Address
Employer’s Tel. No.
Health Ins. Coverage
[ ]
YES
[ ]
NO
Health Insurance Provider
Cert. No.
2.
Gross Weekly Income from All Sources (strike inapplicable words)
a).
Base pay from salary, wages____________________________________
$
b).
Self Employment Income (attach a completed Schedule A)____________
$
c).
Income from overtime-commissions-tips-bonuses-part-time job_________
$
Dividends – interest___________________________________________
d).
$
e).
Income from trusts or annuities__________________________________
$
f).
Pensions and retirement funds__________________________________
$
g).
Social Security_______________________________________________
$
Disability, unemployment insurance or worker’s compensation_________
h).
$
i).
Public Assistance (welfare, A.F.D.C. payments)_____________________
$
j).
Rental from Income Producing Property (
$
attach a completed Schedule B)__
k).
All other sources (including child support, alimony)___________________
$
l). Total Gross Weekly Income (a through k)
$
3.
Itemize Deductions from Gross Income
a).
Federal income tax deductions (claiming
exemptions)_________
$
b).
State income tax deductions (claiming
exemptions)___________
$
c).
F.I.C.A./Medicare_____________________________________________
$
d).
Medical Insurance____________________________________________
$
e).
Union Dues_________________________________________________
$
f). Total Deductions (a through e)
$
4.
Adjusted Net Weekly Income
a).
2 (l) minus 3 (f)_______________________________________________
$
5.
Other Deductions from Salary
a).
Credit Union (Loan Repayment or Savings)________________________
$
b).
Savings____________________________________________________
$
c).
Retirement__________________________________________________
$
Other – Specify (such as Deferred Compensation or 401K)____________
d).
$
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)
CJ-D 301S (11\97)
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