Financial Statement - Short Form - Juvenile Court
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1
2Commonwealth of Massachusetts
The Trial Court
Juvenile Court Department
_________________ Division
Docket No. _______________
FINANCIAL STATEMENT
(SHORT FORM)
____________________________________________ v ___________________________________________
Plaintiff
Defendant
Instructions: If your income equals or exceeds $75,000.00 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 word “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.
1.
Gross W eekly Incom e
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 . . . . . . . . . . . . . . . . . . . . . . .
$ _________
d)
Dividends - Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
e)
Income from trusts or annuities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
f)
Pensions and retirement funds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
h)
Disability, unemployment insurance or worker’s compensation
. . . . . . . . . . . . . . . . . . . . . . .
$ _________
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)
$ _________
2.
Item ize 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)
3.
Adjusted Net W eekly Incom e
2(I) minus 2(f)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
4.
Other Deductions from Salary
a)
Credit Union (Loan Repayment or Savings) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
b)
Savings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
c)
Retirement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
d)
Other - Specify (such as Deferred Compensation or 401(K)__________________________
$ _________
e) Total Deductions (a through d)
$ _________
5.
Net Weekly Income
$ _________
3 minus 4(e) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.
Gross Yearly Income Prior Year
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
(attach copy of all W-2 and 1099 forms per prior year)
7.
W eekly Expenses (Do Not Duplicate W eekly Expenses - Strike Inapplicable W ords)
a)
Rent-Mortgage (PIT)
$ _________
g)
W ater/Sewer
$__________
b)
Homeowner/Tenant Insurance
$ _________
h)
Food
$ _________
c)
Maintenance and Repair
$ _________
i)
Uninsured Medicals
$ _________
d)
Heat (Type________)
$ _________
j)
House Supplies
$ _________
e)
Electricity and/or Gas
$ _________
k)
Laundry and Cleaning
$ _________
f)
Telephone
$ _________
l)
Clothing
$ _________
JV-33 (06/07)
(over)
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