Fillable Printable Financial Statement (Short Form) - Massachusetts
Fillable Printable Financial Statement (Short Form) - Massachusetts
Financial Statement (Short Form) - Massachusetts
Probate and Family Court Department
The Trial Court
Commonwealth of Massachusetts
FINANCIAL STATEMENT
(Short Form)
C.G.F.
CJ-D 301 S (7/07)
V.
Defendant/Petitioner
Plaintiff/Petitioner
Division
PERSONAL INFORMATION
Your Name
Social Security No.
Address
(Street address)
(City/Town)
(State)
(Zip)
Date of Birth
No. of children living with you
Occupation
Employer
Employer's Address
(Street address)
(City/Town)
(Zip)
(State)
Do you have health insurance coverage?
Yes
No
if yes, name of health insurance provider
1.
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)
Worker's compensation
Unemployment insurance
Disability
j) Social Security
Wages
Salary
a) Base pay from
g)
Dividends
Interest
Annuities
Trusts
h)
i)
Retirement funds
Pensions
b) Overtime
c) Part-time job
d) Self-employment (attach a completed schedule A)
e) Tips
f)
Bonuses
Commissions
m)
Child Support
Alimony (actually received)
o) Royalties and other rights
p) Contributions from household member(s)
q) Other (specify)
r) Total Gross Weekly Income/Receipts (add items a-q)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
2.
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.
$
Page 1 of 4
Docket No.
Tel. No.
Tel. No.
Probate and Family Court Department
The Trial Court
Commonwealth of Massachusetts
FINANCIAL STATEMENT
(Short Form)
C.G.F.
CJ-D 301 S (7/07)
Division
WEEKLY EXPENSES
a) Rent or Mortage (PIT)
l) Life Insurance
k) Clothing
j) Laundry and Cleaning
i) House Supplies
h) Food
g) Water/Sewer
f) Telephone
e) Electricity and/or Gas
d) Heat
c) Maintenance and Repair
b) Homeowners/Tenant Insurance
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
m) Medical Insurance
n) Uninsured Medicals
p) Motor Vehicle Expenses
q) Motor Vehicle Payment
r) Child Care
o) Incidentals and Toiletries
s) Other (explain)
t) Total Weekly Expenses (a through s)
8.
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
ITEMIZED DEDUCTIONS FROM GROSS INCOME
a) Federal income tax deductions (claiming
exemptions)
exemptions)
b) State income tax deductions (claiming
c) F.I.C.A. and Medicare
d) Medical Insurance
e) Union Dues
f) Total Deductions (a through e)
ADJUSTED NET WEEKLY INCOME
2(r) minus 3(f)
OTHER DEDUCTIONS FROM SALARY/WAGES
a) Credit Union
b) Savings
c) Retirement
d) Other-Specify (i.e. Child Support, Deferred Compensation or 401K)
e) Total Deductions (a through d)
NET WEEKLY INCOME
4 minus 5(e)
GROSS YEARLY INCOME FROM PRIOR YEAR
(attach copy of all W-2 and 1099 forms for prior year)
Savings
Loan repayment
$
$
$
$
$
$
$
$
$
$
$
$
$
3.
4.
5.
6.
7.
Number of Years you have paid into Social Security
$
Page 2 of 4
Docket No.
Probate and Family Court Department
The Trial Court
Commonwealth of Massachusetts
FINANCIAL STATEMENT
(Short Form)
C.G.F.
CJ-D 301 S (7/07)
Division
ASSETS (attach additional sheet if necessary)
a) Real Estate
Location
Title held in the name of
Fair Market Value $
- Mortgage $
$
$
$
= 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
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):
$
$
$
$
$
$
$
$
$
$
$
g) Other (e.g. stocks, bonds, collections)
10.
f)
LIABILITIES (Do not list expenses shown in item 8 above.)
11.
Creditor
Nature of Debt
Date Incurred
Amount Due
Weekly Payment
a)
d)
c)
b)
$
$
$
$
$
$
$
$
$
$
b) Motor Vehicles
= Equity
- Motor Vehicle Loan $
Fair Market Value $
= Equity
Fair Market Value $
- Motor Vehicle Loan $
h) Total Assets (a through g)
e) Total Liabilities
Financial Institution or Plan Name and Account Number
Page 3 of 4
Docket No.
Probate and Family Court Department
The Trial Court
Commonwealth of Massachusetts
FINANCIAL STATEMENT
(Short Form)
C.G.F.
CJ-D 301 S (7/07)
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.
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
CERTIFICATION
(Signature of attorney)
(Print name)
B.B.O. #
Tel. No.
(Zip)
(State)
(City/Town)
(Street address)
Date
Division
INSTRUCTIONS: In any case where an attorney is appearing for a party, said attorney
MUST complete the Statement by Attorney.
Page 4 of 4
Docket No.
