Cj-D 301 S Financial Statement Short Form (Portuguese/english) Page 3
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4__________________
PORTUGUESE
(Anticipated range of total legal expense to litigate this action)
Estado de Massachusetts
(Commonwealth of Massachusetts)
Tribunal de Justiça
Comarca
_________________
N° do Processo
_________________
(Division)
(The Trial Court)
(Docket No.)
Vara de Família e Sucessões
(Probate and Family Court Department)
RELATÓRIO FINANCEIRO
(FINANCIAL STATEMENT)
(Formulário simplificado)
(Short Form)
10. BENS
(se for necessário, anexar outra folha)
(ASSETS)
(attach additional sheet if necessary)
a) Imóvel
(Real Estate)
Localização
_____________________________________________________________
(Location)
Escritura do imóvel em nome de
_________________________________
(Title held in the name of)
Valor de mercado $_________________________ - Hipoteca $_________________________= Patrimônio líquido
$_____________________
(Fair Market Value)
(Mortgage)
(Equity)
b) Veículos
(Motor Vehicles)
Valor de mercado $_________________________ - Empréstimo $______________________ = Patrimônio líquido
$_____________________
(Fair Market Value)
(Motor Vehicle Loan)
(Equity)
Valor de mercado $_________________________ - Empréstimo $______________________ = Patrimônio líquido
$_____________________
(Fair Market Value)
(Motor Vehicle Loan)
(Equity)
c) IRA, Keogh, pensão, participação nos lucros, outros planos de aposentadoria
(IRA, Keogh, Pension, Profit Sharing, Other Retirement Plans)
Nome da instituição financeira ou nome do plano e número da conta
(Financial Institution or Plan Name and Account Number)
_____________________________________________________________________________
$_____________________
_____________________________________________________________________________
$_____________________
_____________________________________________________________________________
$_____________________
d) Fundo/s de aposentadoria com imposto diferido
$_____________________
[Tax Deferred Annuity Plan(s)]
e) Seguro de vida: Valor de resgate líquido atualizado
$_____________________
(Life Insurance: Present Cash Value)
f) Cadernetas de poupança & contas correntes, aplicações no mercado financeiro, certificados de
depósitos bancários, mantidos individual ou conjuntamente, em nome de terceiros sendo você o
beneficiário ou em seu nome tendo seu/s dependente/s menor/es como beneficiários
[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)]
Nome da instituição financeira ou nome do plano e número da conta
(Financial Institution or Plan Name and Account Number)
_____________________________________________________________________________
$_____________________
_____________________________________________________________________________
$_____________________
_____________________________________________________________________________
$_____________________
g) Outros (por ex.: ações, obrigações, cobranças)
[Other (e.g. stocks, bonds, collections)]
_____________________________________________________________________________
$_____________________
_____________________________________________________________________________
$_____________________
h) Valor total dos bens (somar linhas a, b, c, d, e, f, g)
[Total Assets (a through g)]
11. DÍVIDAS (Não liste as despesas declaradas no item 8 acima)
[LIABILITIES (Do not list expenses shown in item 8 above)]
______________________________________________________________________________________________________________________________________
Credor
Natureza da dívida
Data de incidência
Saldo devedor
Pagamento Semanal
(Creditor)
(Nature of Debt)
(Date Incurred)
(Amount Due)
(Weekly Payment)
______________________________________________________________________________________________________________________________________
a)
$
$
_________________________________________________________________________________________________________________________________________________________________________________
b)
$
$
_________________________________________________________________________________________________________________________________________________________________________________
c)
$
$
_________________________________________________________________________________________________________________________________________________________________________________
d)
$
$
_________________________________________________________________________________________________________________________________________________________________________________
$
$
e) Total devido
(Total Liabilities)
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CJ-D 301 S (7/07) _ Financial Statement (Short Form). OCIS. December, 2010
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