Commonwealth of Massachusetts The Trial Court Probate and Family Court Department Division Docket No. FINANCIAL STATEMENT (Long Form) INSTRUCTIONS: If your income is less than $75,000.00 annually, you must complete the SHORT FORM financial statement, unless otherwise ordered by the court. vs. Plaintiff/Petitioner I. Defendant/Petitioner PERSONAL INFORMATION Your Name Social Security No. Address (Street address) (City/Town) Date of Birth Tel. No. Occupation (State) (Zip) No. of children living with you Employer Employer's Address (Street address) (City/Town) (State) Do you have health insurance coverage? Employer's Telephone No. (Zip) Yes No If yes, name of health insurance provider II. 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 $ Retirement funds $ i) Pensions $ j) Social Security k) Disability Unemployment insurance Worker's compensation $ l) Public Assistance (welfare, A.F.D.C. payments) $ 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 L (4/07) Page 1 of 9 $ C.G.F. American LegalNet, Inc. www.FormsWorkflow.com Commonwealth of Massachusetts The Trial Court Probate and Family Court Department Division Docket No. FINANCIAL STATEMENT (Long Form) III. WEEKLY DEDUCTIONS FROM GROSS INCOME TAX WITHOLDING $ a) Federal tax witholding/estimated payments Number of withholding allowances claimed $ b) State tax witholding/estimated payments Number of withholding allowances claimed OTHER DEDUCTIONS c) F.I.C.A. $ d) Medicare $ e) Medical Insurance $ f) Dental Insurance $ g) Vision Insurance $ h) Union Dues $ i) Child Support $ j) Spousal Support $ k) Retirement $ l) Savings $ m) Deferred Compensation $ n) Credit Union (Loan) $ o) Credit Union (Savings) $ p) Charitable Contributions $ q) Life Insurance $ r) Other (specify) $ $ $ s) Total Weekly Deductions from Pay (Add items a-r) IV. $ NET WEEKLY INCOME a) Enter total gross weekly income/receipts from II(r) $ b) Enter total weekly deductions from pay from III(s) -$ =$ c) Net Weekly Income V. $ GROSS 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 CJ-D 301 L (4/07) Page 2 of 9 C.G.F. American LegalNet, Inc. www.FormsWorkflow.com Commonwealth of Massachusetts The Trial Court Probate and Family Court Department Division Docket No. FINANCIAL STATEMENT (Long Form) VI. WEEKLY EXPENSES NOT DEDUCTED FROM PAY Rent $ Mortgage (Principal, Interest - Taxes and Insurance, if escrowed) $ Property taxes and assessments $ Homeowner/Tenant Insurance $ Maintenance Fees $ Condominium Fees Heat $ Electricity $ Propane $ Natural Gas $ Telephone Water $ Sewer Food $ House Supplies $ Laundry $ Dry Cleaning $ Clothing $ Life insurance $ Medical insurance $ Dental insurance $ Vision insurance $ Uninsured Medical $ Uninsured Dental $ Motor Vehicle Expenses $ Fuel $ Insurance $ Maintenance $ Loan payment(s) $ Entertainment $ Vacation $ Cable TV $ Child Support (attach a copy of the order, if issued by a different court) $ Child(ren)'s Day Care Expense $ Child(ren)'s Education $ Education (self) $ CJ-D 301 L (4/07) Page 3 of 9 C.G.F. American LegalNet, Inc. www.FormsWorkflow.com Commonwealth of Massachusetts The Trial Court Probate and Family Court Department Division Docket No. FINANCIAL STATEMENT (Long Form) Employment related expenses (which are not reimbursed) Uniforms $ Travel $ Required continuing education $ Other (specify) $ Lottery tickets $ Charitable Contributions $ Child(ren)'s allowance $ Extraordinary travel expenses for visitation with child(ren) $ Other (specify) $ $ $ $ TOTAL WEEKLY EXPENSES NOT DEDUCTED FROM PAY VII. COUNSEL FEES Retainer amount(s) paid to your attorney(s) $ Legal fees incurred, to date, against the retainer(s) $ Anticipated range of total legal expense to litigate this action $ to $ VIII. ASSETS INSTRUCTIONS: If additional space is needed for any answer or to disclose additional assets not listed below please attach additional pages. A. REAL ESTATE Real Estate-Primary Residence Address (Street address) (City/Town) (State) Title held in the name of Purchase Price of the Property $ Year of Purchase Current Assessed Value of the Property $ Date of Last Assessment $ Fair Market Value of the Property Outstanding 1st mortgage - $ Outstanding 2nd mortgage or home equity loan - $ Equity = $ CJ-D 301 L (4/07) Page 4 of 9 C.G.F. American LegalNet, Inc. www.FormsWorkflow.com Commonwealth of Massachusetts The Trial Court Probate and Family Court Department Division Docket No. FINANCIAL STATEMENT (Long Form) Real Estate-Vacation or Second Home (including interest in time share) Address (Street address) (City/Town) (State) Title held in the name of $ Purchase Price of the Property Year of Purchase Current Assessed Value of the Property $ Date of Last Assessment $ Fair Market Value of the Property Outstanding 1st mortgage - $ Outstanding 2nd mortgage or home equity loan - $ Equity = $ B. MOTOR VEHICLES including cars, trucks, ATV's, snowmobiles, tractors, motorcycles, boats, recreational vehicles, aircraft, farm machinery etc. Type Make Model Purchase Price of vehicle $ Year of Purchase Fair Market Value $ Outstanding Loan - $ Equity = $ Type Make Model Purchase Price of vehicle $ Year of Purchase Fair Market Value $ Outstanding Loan - $ Equity = $ C. PENSIONS Institution Account Number Listed Beneficiary Current Balance/Value Defined Benefit Plan $ Defined Contribution Plan $ CJ-D 301 L (4/07) Page 5 of 9 C.G.F. American LegalNet, Inc. www.FormsWorkflow.com Commonwealth of Massachusetts Division The Trial Court Probate and Family Court Department Docket No. FINANCIAL STATEMENT (Long Form) D. OTHER ASSETS. List assets 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). Institution Account Number Current Balance/Value $ Checking Account(s) $ $ Savings Account(s) $ $ Cash on Hand $ Certificate(s) of Deposit $ $ Credit Union Account(s) $ $ Funds Held in Escrow $ $ Stocks $ $ Bonds $ $ Bond Fund(s) $ $ Notes Held $ $ Cash in Brokerage Account(s) $ $ Money Market Account(s) CJ-D 301 L (4/07) Listed Beneficiary $ Page 6 of 9 C.G.F. American LegalNet, Inc. www.FormsWorkflow.com Commonwealth of Massachusetts Division The Trial Court Probate and Family Court Department Docket No. FINANCIAL STATEMENT (Long Form) Institution Account Number Listed Beneficiary Current Balance/Value $ U.S. Savings Bond(s) $ $ IRAs $ $ Keough $ $ Profit Sharing $ $ Deferred Compensation $ $ Other Retirement Plans $ Annuity (please specify $ whether a tax deferred annuity or a tax sheltered annuity) $ Life Insurance Cash Value (please specify whether $ a term or a whole universal life insurance policy) $ $ Judgments/Liens $ Pending Legacies and/or Inheritances $ Jewelry $ Contents of Safe or Safe Deposit Box $ Firearms $ Collections $ Tools/Equipment $ Crops/Livestock $ Home Furnishings $ Arts and Antiques $ Other (please specify): $ Other (please specify): $ $ TOTAL ASSETS CJ-D 301 L (4/07) Page 7 of 9 C.G.F. American LegalNet, Inc. www.FormsWorkflow.com Commonwealth of Massachusetts Division The Trial Court Probate and Family Court Department Docket No. FINANCIAL STATEMENT (Long Form) IX. LIABILITIES : List loans, credit card debt, consumer debt, installment debt, etc. which are NOT listed elsewhere. CREDITOR NATURE OF DEBT DATE INCURRED AMOUNT DUE WEEKLY PAYMENT $ $ $ $ $ $ $ $ $ $ $ $ $ $ Page 8 of 9 $ $ CJ-D 301 L (4/07) $ $ $ $ $ TOTAL LIABILITIES $ $ $ C.G.F. American LegalNet, Inc. www.FormsWorkflow.com Commonwealth of Massachusetts The Trial Court Probate and Family Court Department Division Docket No. FINANCIAL STATEMENT (Long Form) CERTIFICATION BY AFFIANT 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. I UNDERSTAND THAT WILLFUL MISREPRESENTATION OF ANY OF THE INFORMATION PROVIDED WILL SUBJECT ME TO SANCTIONS AND MAY RESULT IN CRIMINAL CHARGES BEING FILED AGAINST ME. Date Signature COMMONWEALTH OF MASSACHUSETTS County of Then personally appeared the above and declared the foregoing to be true and correct, before me this day of Notary Public My Commission Expires: 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 L (4/07) Page 9 of 9 C.G.F. American LegalNet, Inc. www.FormsWorkflow.com