Form C J-D 301 S PDF Details

When navigating through legal proceedings in the Probate and Family Court Department in Massachusetts, the Short Financial Statement form serves as a critical component. This form plays a pivotal role for individuals with an annual income of less than $75,000. It is a tool designed meticulously to capture comprehensive personal and financial information, including but not limited to personal details, gross weekly income from various sources, and the intricacies of deductions. The form meticulously breaks down different income streams such as salary, wages, overtime, and self-employment earnings among others. It also delves into detailed deductions leading to the net weekly income calculation. Furthermore, the statement delves into yearly income from the previous year, weekly expenses across numerous categories, counsel fees, extensive asset documentation, and current liabilities excluding regular expenses covered elsewhere in the document. This rigorous documentation culminates with a certification by the person completing it, ensuring all information is true and accurate to the best of their knowledge, under penalty of perjury. Whether for determining child support obligations, alimony, or other financial matters in court proceedings, the Short Financial Statement form is indispensable in providing a clear financial picture to the court.

QuestionAnswer
Form NameMassachusetts Short Form Financial Statement
Form Length4 pages
Fillable?Yes
Fillable fields173
Avg. time to fill out35 min 40 sec
Other namesma child support short forms, short form financial statement massachusetts, financial statement short form, ma divorce financial statement

Form Preview Example

 

 

Commonwealth of Massachusetts

 

Division

 

The Trial Court

Docket No.

 

Probate and Family Court Department

 

FINANCIAL STATEMENT

(Short Form)

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Plaintiff/Petitioner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Defendant/Petitioner

 

 

 

 

 

 

1. PERSONAL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security No.

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Street address)

 

 

 

 

 

 

 

 

 

 

 

(City/Town)

 

 

(State)

 

 

(Zip)

 

 

 

 

Tel. No.

 

 

 

 

Date of Birth

 

 

 

 

No. of children living with you

 

 

 

 

 

Occupation

 

 

 

 

 

 

 

 

 

 

 

Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer's Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Street address)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(City/Town)

(State)

 

(Zip)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tel. No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you have health insurance coverage?

□ Yes

□ No

 

 

 

if yes, name of health insurance provider

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. GROSS WEEKLY INCOME/RECEIPTS FROM ALL SOURCES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a) Base pay from □ Salary □ Wages

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

b) Overtime

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c) Part-time job

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d) Self-employment (attach a completed schedule A)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e) Tips

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f)

□ Commissions

 

□ Bonuses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

g)

□ Dividends

 

□ Interest

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

h)

□ Trusts

 

□ Annuities

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

i)

□Pensions

 

□ Retirement funds

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

j) Social Security

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

k)

□Disability

□Unemployment insurance

□Worker's compensation

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

l) Public Assistance (e.g. welfare, TAFDC, SNAP) (not included in gross income for child support)

 

 

 

 

 

 

 

 

 

 

 

m)

□ Child Support

 

□ Alimony (actually received)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

n) Rental from income producing property (attach a completed Schedule B)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

o) Royalties and other rights

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

p) Contributions from household member(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

q) Other (specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

r) Total Gross Weekly Income/Receipts (add items a-q)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CJ-D 301 S 9/15/17

Page 1 of 4

C.G.F.

 

 

 

 

Commonwealth of Massachusetts

 

 

 

 

 

 

 

 

Division

 

The Trial Court

Docket No.

 

 

 

 

Probate and Family Court Department

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FINANCIAL STATEMENT

 

 

 

 

 

 

 

 

 

 

 

 

(Short Form)

 

 

 

 

 

 

 

3.

ITEMIZED DEDUCTIONS FROM GROSS INCOME

 

 

 

 

 

 

 

 

a) Federal income tax deductions (claiming

 

 

exemptions)

$

 

 

 

 

 

 

b) State income tax deductions (claiming

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

exemptions)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c) F.I.C.A. and Medicare

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d) Medical Insurance

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e) Union Dues

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f) Total Deductions (a through e)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

ADJUSTED NET WEEKLY INCOME

 

2(r) minus 3(f)

$

 

 

 

 

 

 

 

 

 

 

 

5.

OTHER DEDUCTIONS FROM SALARY/WAGES

 

 

 

 

 

 

 

 

a) Credit Union □ Loan repayment

□ Savings

$

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

b) Savings

 

 

 

 

 

 

 

 

 

 

 

 

c) Retirement

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d) Other-Specify (i.e. Child Support, Deferred Compensation or 401K)

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e) Total Deductions (a through d)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

NET WEEKLY INCOME

 

4 minus 5(e)

$

 

 

 

 

 

 

 

 

 

 

 

7.

GROSS YEARLY INCOME FROM PRIOR YEAR

$

 

 

 

 

 

 

 

 

 

 

 

(attach copy of all W-2 and 1099 forms for prior year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of Years you have paid into Social Security

 

 

 

 

 

 

 

8.

WEEKLY EXPENSES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a) Rent or Mortage (PIT)

$

b) Homeowners/Tenant Insurance

$

c) Maintenance and Repair

$

d) Heat

$

e) Electricity and/or Gas

$

f) Telephone

$

g) Water/Sewer

$

h) Food

$

i) House Supplies

$

j) Laundry and Cleaning

$

k) Clothing

$

l) Life Insurance

$

m) Medical Insurance

$

n) Uninsured Medicals

$

o) Incidentals and Toiletries

$

p) Motor Vehicle Expenses

$

q) Motor Vehicle Payment

$

r) Child Care

$

s) Other (explain)

 

 

 

$

 

 

$

 

 

 

t) Total Weekly Expenses (a through s)

 

$

 

 

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 $

 

 

CJ-D 301 S 9/15/17

Page 2 of 4

C.G.F.

Division

 

Commonwealth of Massachusetts

Docket No.

 

The Trial Court

 

 

Probate and Family Court Department

 

 

 

 

 

 

FINANCIAL STATEMENT

 

 

 

(Short Form)

 

10.ASSETS (attach additional sheet if necessary)

a) Real Estate

 

 

 

 

 

 

 

Location

 

 

 

 

 

 

 

 

Title held in the name of

 

 

 

 

 

 

 

 

Fair Market Value $

 

 

- Mortgage $

 

 

 

 

= Equity $

b) Motor Vehicles

 

 

 

 

 

 

 

Fair Market Value $

 

 

- Motor Vehicle Loan $

 

 

 

= Equity $

Fair Market Value $

 

 

- Motor Vehicle Loan $

 

 

 

= 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

$

f)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):

Financial Institution or Plan Name and Account Number

$

$

$

g) Other (e.g. stocks, bonds, collections)

$

$

h) Total Assets (a through g)

$

11.LIABILITIES (Do not list expenses shown in item 8 above.)

a)

b)

c)

d)

Creditor

Nature of Debt

Date Incurred

Amount Due

Weekly Payment

$$

$$

$$

$$

e) Total Liabilities

$

$

CJ-D 301 S 9/15/17

Page 3 of 4

C.G.F.

 

 

Commonwealth of Massachusetts

 

Division

 

The Trial Court

Docket No.

 

Probate and Family Court Department

 

 

 

 

 

FINANCIAL STATEMENT

 

 

 

(Short Form)

 

CERTIFICATION

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

INSTRUCTIONS: In any case where an attorney is appearing for a party, said attorney

MUST complete the Statement by Attorney.

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.

Date

(Signature of attorney)

(Print name)

(Street address)

(City/Town)

(State)

(Zip)

Tel. No.

B.B.O. #

CJ-D 301 S 9/15/17

Page 4 of 4

C.G.F.

How to Edit Massachusetts Short Form Financial Statement Online for Free

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Step 1: Press the orange "Get Form Now" button on this webpage.

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These areas will frame the PDF file that you'll be completing:

ma divorce financial statement gaps to complete

The system will require you to submit the Tel No, Street address, CityTown, Do you have health insurance, State, Yes, Zip, if yes name of health insurance, GROSS WEEKLY INCOMERECEIPTS FROM, a Base pay from, Salary, Wages, b Overtime, c Parttime job, and d Selfemployment attach a field.

Entering details in ma divorce financial statement stage 2

Write down any details you may need within the space o Royalties and other rights, p Contributions from household, q Other specify, r Total Gross Weekly, CJD S, Page of, and CGF.

part 3 to filling out ma divorce financial statement

Identify the rights and obligations of the sides inside the section Division, Commonwealth of Massachusetts The, Docket No, ITEMIZED DEDUCTIONS FROM GROSS, a Federal income tax deductions, b State income tax deductions, exemptions, exemptions, c FICA and Medicare, d Medical Insurance, e Union Dues, f Total Deductions a through e, ADJUSTED NET WEEKLY INCOME, r minus f, and OTHER DEDUCTIONS FROM SALARYWAGES.

step 4 to filling out ma divorce financial statement

Finalize by taking a look at these sections and completing them accordingly: NET WEEKLY INCOME, minus e, GROSS YEARLY INCOME FROM PRIOR, Number of Years you have paid into, WEEKLY EXPENSES, d Heat, f Telephone, e Electricity andor Gas, a Rent or Mortage PIT, b HomeownersTenant Insurance c, j Laundry and Cleaning, i House Supplies, g WaterSewer, k Clothing, and h Food.

Finishing ma divorce financial statement step 5

Step 3: Choose the button "Done". The PDF form can be exported. You can easily obtain it to your pc or send it by email.

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