Financial Statement – Massachusetts Courts

This financial statement form is designed to collect detailed information about an individual’s financial status. The form is divided into several sections to capture various aspects of personal and financial data. This form is comprehensive, ensuring that all necessary financial details are captured to assess an individual’s financial situation accurately.

To ensure accurate and complete information on financial statement form, please follow these instructions carefully while filling out the financial statement form:

– Personal Information

1. Name: Enter your full legal name.
2. Date of Birth: Provide your date of birth in the format MM/DD/YYYY.
3. Social Security Number: Enter your social security number.
4. Address: Write your current residential address.
5. Telephone Number: Provide a valid contact number.

– Employment Information

1. Employer: Name of your current employer.
2. Employer’s Address: Enter the full address of your employer.
3. Position Held: Mention your job title or position.
4. Employer’s Telephone Number: Provide a contact number for your employer.

– Unemployment Information (if applicable)

1. Duration of Unemployment: State how long you have been unemployed.
2. Reason for Unemployment: Explain the reason for your unemployment.
3. Previous Employer: Provide the name of your last employer.
4. Previous Position: Mention your job title at your previous employment.

– Income Details

1. Gross Pay
   • Weekly: Enter your weekly gross income.
   • Last Year: Provide your total gross income for the previous year.
2. Net Pay
   • Weekly: Enter your weekly net income (after deductions).
   • Per Month: Provide your net income on a monthly basis.
3. Social Security, Pension, Retirement Income: Enter the monthly amount received from these sources.
4. Unemployment, Disability, Worker’s Compensation: Provide the monthly amount received if applicable.
5. Public Assistance (Welfare, AFDC, SSI, VA): Enter the monthly amount received from public assistance programs.
6. Child Support or Alimony Income:
   • Weekly: Provide the weekly amount.
   • Per Month: Enter the monthly amount.
7. Other Income
   • Amount: Provide the total amount of other income.
   • Source: Specify the source of this other income.

– Assets

1. Property Owned
   • Value: Enter the current market value of your property.
   • I.T. Payments: Provide the amount of P.I.T. payments.
   • Balance Due: Enter the remaining balance due on the property.
2. Bank Accounts
   • Checking: Enter the current balance of your checking account.
   • Savings: Enter the current balance of your savings account.
3. Car
   • Year and Make: Provide the year and make of your car.
   • Value: Enter the current market value of your car.
4. Other Assets: List any other assets you own along with their values.

– Liabilities

1. Detailed List of Liabilities: Enter details of all your current liabilities including amounts owed.

– Current Income and Expenses

1. Gross Income
   • Weekly: Enter your gross weekly income.
   • Monthly: Enter your gross monthly income.
2. Deductions
   • Federal Tax: Provide the amount deducted for federal taxes.
   • State Tax: Provide the amount deducted for state taxes.
   • Social Security: Enter the amount deducted for social security.
   • Health Insurance: Enter the amount deducted for health insurance.
   • Pension: Provide the amount deducted for pension contributions.
   • Other: List any other deductions.
3. Net Income
   • Weekly: Enter your weekly net income.
   • Monthly: Enter your monthly net income.
4. Expenses
   • Rent: Enter your monthly rent.
   • Heat: Provide the monthly cost of heating.
   • Gas: Provide the monthly cost of gas.
   • Electric: Provide the monthly cost of electricity.
   • Food: Enter your monthly food expenses.
   • Clothing: Provide the monthly cost of clothing.
   • Other: List any other monthly expenses.
5. Total Expenses: Calculate and enter the total of all monthly expenses.
6. Net Income Minus Expenses: Subtract the total expenses from your net income to determine your remaining income.

Additional Information

1. Persons Living with You: List all individuals living with you.
2. Other Facts Relevant to Ability to Pay: Provide any additional information that may affect your ability to pay.

Declaration

1. Signature: Sign the form to certify that the information provided is accurate.
2. Name: Print your full name.
3. Address: Enter your current address.
4. Telephone Number: Provide your contact number.
5. Date: Enter the date of form completion in MM/DD/YYYY format.

Make sure to review all the information for accuracy before submitting the form. This detailed information will help in assessing your financial status comprehensively. Top of FormBottom of Form