Fillable Printable Financial Statement (Long Form) - Massachusetts
Fillable Printable Financial Statement (Long Form) - Massachusetts
Financial Statement (Long Form) - Massachusetts
Probate and Family Court Department
The Trial Court
Commonwealth of Massachusetts
CJ-D 301 L (4/07)
C.G.F.
FINANCIAL STATEMENT
(Long Form)
Plaintiff/Petitioner
vs.
Defendant/Petitioner
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)
Employer's Phone No.
Do you have health insurance coverage?
Yes
No
If yes, name of health insurance provider
GROSS WEEKLY INCOME/RECEIPTS FROM ALL SOURCES
n) Rental from income producing property (attach a completed Schedule B)
l) Public Assistance (welfare, A.F.D.C. payments)
k)
j) Social Security
Salary
Wages
Commissions
Bonuses
Dividends
Interest
Trusts
Annuities
Pensions
Retirement funds
Disability
Unemployment insurance
Worker's compensation
Child Support
Alimony (actually received)
a) Base pay from
g)
h)
i)
b) Overtime
c) Part-time job
d) Self-employment (attach a completed schedule A)
e) Tips
f)
m)
o) Royalties and other rights
p) Contributions from household member(s)
q) Other (specify)
r) Total Gross Weekly Income/Receipts (add items a-q)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
I.
II.
Division
INSTRUCTIONS: If your income is less than $75,000.00 annually, you must complete the SHORT FORM financial
statement, unless otherwise ordered by the court.
Page 1 of 9
Docket No.
Probate and Family Court Department
The Trial Court
Commonwealth of Massachusetts
CJ-D 301 L (4/07)
C.G.F.
FINANCIAL STATEMENT
(Long Form)
Division
Docket No.
WEEKLY DEDUCTIONS FROM GROSS INCOME
III.
TAX WITHOLDING
a) Federal tax witholding/estimated payments
Number of withholding allowances claimed
b) State tax witholding/estimated payments
Number of withholding allowances claimed
OTHER DEDUCTIONS
c) F.I.C.A.
d) Medicare
e) Medical Insurance
h) Union Dues
i) Child Support
j) Spousal Support
k) Retirement
l) Savings
m) Deferred Compensation
n) Credit Union (Loan)
o) Credit Union (Savings)
p) Charitable Contributions
q) Life Insurance
r) Other (specify)
s) Total Weekly Deductions from Pay (Add items a-r)
NET WEEKLY INCOME
IV.
a) Enter total gross weekly income/receipts from II(r)
b) Enter total weekly deductions from pay from III(s)
c) Net Weekly Income
GROSS INCOME FROM PRIOR YEAR
V.
(attach copy of all W-2 and 1099 forms for prior year)
Number of years you have paid into Social Security
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
f) Dental Insurance
g) Vision Insurance
$
$
-
=
Page 2 of 9
Probate and Family Court Department
The Trial Court
Commonwealth of Massachusetts
CJ-D 301 L (4/07)
C.G.F.
FINANCIAL STATEMENT
(Long Form)
Division
VI.
Rent
Mortgage (Principal, Interest - Taxes and Insurance, if escrowed)
Education (self)
Child(ren)'s Education
Child(ren)'s Day Care Expense
Child Support (attach a copy of the order, if issued by a different court)
Cable TV
Vacation
Entertainment
Loan payment(s)
Maintenance
Insurance
Fuel
Motor Vehicle Expenses
Medical insurance
Life insurance
Clothing
Dry Cleaning
Laundry
House Supplies
Food
Telephone
Electricity
Heat
Homeowner/Tenant Insurance
Property taxes and assessments
Maintenance Fees
Condominium Fees
Natural Gas
Propane
Sewer
Water
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
WEEKLY EXPENSES NOT DEDUCTED FROM PAY
Dental insurance
Vision insurance
Uninsured Medical
Uninsured Dental
Page 3 of 9
Docket No.
Probate and Family Court Department
The Trial Court
Commonwealth of Massachusetts
CJ-D 301 L (4/07)
C.G.F.
FINANCIAL STATEMENT
(Long Form)
Uniforms
Extraordinary travel expenses for visitation with child(ren)
Child(ren)'s allowance
Lottery tickets
Required continuing education
Travel
Employment related expenses (which are not reimbursed)
Other (specify)
Other (specify)
TOTAL WEEKLY EXPENSES NOT DEDUCTED FROM PAY
$
$
$
$
$
$
$
$
$
$
$
$
ASSETS
VIII.
INSTRUCTIONS: If additional space is needed for any answer or to disclose additional assets not listed below please
attach additional pages.
A. REAL ESTATE
Real Estate-Primary Residence
Address
(Street address)
(City/Town)
(State)
Title held in the name of
Outstanding 1st mortgage
Outstanding 2nd mortgage or home equity loan
Equity
Purchase Price of the Property
Year of Purchase
Current Assessed Value of the Property
Date of Last Assessment
Fair Market Value of the Property
Division
$
$
$
$
$
$
Charitable Contributions
COUNSEL FEES
VII.
Retainer amount(s) paid to your attorney(s)
Legal fees incurred, to date, against the retainer(s)
Anticipated range of total legal expense to litigate this action
$
$
$
to
$
-
-
=
Page 4 of 9
Docket No.
Probate and Family Court Department
The Trial Court
Commonwealth of Massachusetts
CJ-D 301 L (4/07)
C.G.F.
FINANCIAL STATEMENT
(Long Form)
B. MOTOR VEHICLES including cars, trucks, ATV's, snowmobiles, tractors,
motorcycles, boats, recreational vehicles, aircraft, farm machinery etc.
Type
Make
Model
Purchase Price of vehicle
Year of Purchase
Fair Market Value
Outstanding Loan
Equity
C. PENSIONS
$
$
$
$
Institution
Account Number
Listed Beneficiary
Current Balance/Value
Defined Benefit Plan
Defined Contribution Plan
$
$
Title held in the name of
(State)
(City/Town)
(Street address)
Address
Real Estate-Vacation or Second Home (including interest in time share)
Division
Outstanding 1st mortgage
Outstanding 2nd mortgage or home equity loan
Equity
Purchase Price of the Property
Year of Purchase
Current Assessed Value of the Property
Date of Last Assessment
Fair Market Value of the Property
$
$
$
$
$
$
-
-
=
=
-
Type
Make
Model
Purchase Price of vehicle
Year of Purchase
Fair Market Value
Outstanding Loan
Equity
$
$
$
$
=
-
Page 5 of 9
Docket No.
Probate and Family Court Department
The Trial Court
Commonwealth of Massachusetts
CJ-D 301 L (4/07)
C.G.F.
FINANCIAL STATEMENT
(Long Form)
Division
D. OTHER ASSETS. List assets 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).
Institution
Account Number
Listed Beneficiary
Current Balance/Value
Checking Account(s)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Savings Account(s)
Cash on Hand
Money Market Account(s)
Cash in Brokerage
Account(s)
Notes Held
Bond Fund(s)
Bonds
Stocks
Funds Held in Escrow
Credit Union Account(s)
Certificate(s) of Deposit
Page 6 of 9
Docket No.
Probate and Family Court Department
The Trial Court
Commonwealth of Massachusetts
CJ-D 301 L (4/07)
C.G.F.
FINANCIAL STATEMENT
(Long Form)
Institution
Account Number
Listed Beneficiary
Current Balance/Value
U.S. Savings Bond(s)
IRAs
Keough
Contents of Safe or Safe
Deposit Box
Jewelry
Pending Legacies and/or
Inheritances
Judgments/Liens
Life Insurance Cash
Value (please specify whether
a term or a whole universal life
insurance policy
)
Annuity (please specify
whether a tax deferred annuity
or a tax sheltered annuity)
Other Retirement Plans
Deferred Compensation
Profit Sharing
Firearms
Collections
Tools/Equipment
Crops/Livestock
Home Furnishings
Arts and Antiques
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Other (please specify):
Other (please specify):
TOTAL ASSETS
Division
$
Page 7 of 9
Docket No.
Probate and Family Court Department
The Trial Court
Commonwealth of Massachusetts
CJ-D 301 L (4/07)
C.G.F.
FINANCIAL STATEMENT
(Long Form)
$
$
LIABILITIES : List loans, credit card debt, consumer debt, installment debt, etc. which are NOT listed elsewhere.
IX.
CREDITOR
NATURE OF DEBT
DATE INCURRED
AMOUNT DUE
WEEKLY PAYMENT
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
TOTAL LIABILITIES
Division
Page 8 of 9
Docket No.
Probate and Family Court Department
The Trial Court
Commonwealth of Massachusetts
CJ-D 301 L (4/07)
C.G.F.
FINANCIAL STATEMENT
(Long Form)
Division
CERTIFICATION BY AFFIANT
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. I UNDERSTAND THAT WILLFUL MISREPRESENTATION OF ANY OF THE
INFORMATION PROVIDED WILL SUBJECT ME TO SANCTIONS AND MAY RESULT IN CRIMINAL CHARGES BEING
FILED AGAINST ME.
Date
Signature
COMMONWEALTH OF MASSACHUSETTS
County of
Then personally appeared the above
and declared the
foregoing to be true and correct, before me this
day of
Notary Public
My Commission Expires:
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.
(Signature of attorney)
(Print name)
B.B.O. #
(Zip)
(State)
(City/Town)
(Street address)
Date
Page 9 of 9
Docket No.
Tel. No.
