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.
$
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