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)
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
$
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Docket No.
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