FINANCIAL STATEMENT DOCKET NUMBER Trial Court of Massachusetts Small Claims Session OF JUDGMENT DEBTOR CASE NAME CURRENT COURT NAME OF JUDGMENT DEBTOR (the person who lost the case and owes money) HOME ADDRESS HOME TELEPHONE NUMBER SOCIAL SECURITY NUMBER DRIVER’S LICENSE NUMBER & STATE OCCUPATION MARITAL STATUS DATE OF BIRTH NO. & AGE OF CHILDREN LIVING WITH YOU EMPLOYER’S NAME & ADDRESS HOW LONG WITH EMPLOYER? INCOME (list all sources) ASSETS (list value of all assets) Your Gross Pay: $ . . . . . . . . . . . . per week Your Take-Home Pay: $ . . . . . . . . . . . . per week Address: ......................... Spouse’s Take-Home Pay: $ . . . . . . . . . . . . per week Other Owner(s): ......................... Child Support Income: $ . . . . . . . . . . . . per week Mortgage Balance: $......... $......... Pension: $ . . . . . . . . . . . . per week Fair Market Value: $......... $......... AFDC/SSI: $ . . . . . . . . . . . . per week Rental Income: $......... $......... Other (itemize on back): $ . . . . . . . . . . . . per week Vehicle(s)/Boat(s) You Own VEHICLE/BOAT 1 VEHICLE/BOAT 2 Total Weekly Income: $ . . . . . . . . . . . . per week Year/Make & Model: ......................... Purchase Year: ......................... Purchase Price: $............ $ ........ Amount Owed: $............ $ ........ EXPENSES Real Estate you own or co-own OTHER RESIDENCE Rent/Mortgage: $ . . . . . . . . . . . per week Utilities: $ . . . . . . . . . . . per week Food: $ . . . . . . . . . . . per week Bank/Credit Union: ......................... Alimony/Child Support: $ . . . . . . . . . . . per week Account No.: ......................... Child Care: $ . . . . . . . . . . . per week Balance: $............ $ ........ Transportation: $ . . . . . . . . . . . per week Expected Tax Refund: Insurance: $ . . . . . . . . . . . per week How much money do you have in cash? $ . . . . . . . . . . . . . Entertainment (including cable): $ . . . . . . . . . . . per week Other (itemize on back): $ . . . . . . . . . . . per week Total Weekly Expenses: $ . . . . . . . . . . . per week Bank Accounts SAVINGS CHECKING $....................... Have you disposed of or transferred any asset since this claim was brought? (If so, explain on back.) 9 No 9 Yes (List on back anything of value not listed above that you own or co-own, or that is held for you by another.) DEBTS (list all debts not included above in your expenses – e.g., credit card debts) TOTAL DUE WEEKLY PAYMENT 1 ....................................................................... $........... $.......... 2 ....................................................................... $........... $.......... 3 ....................................................................... $........... $.......... NATURE OF DEBT CREDITOR DATE OF ORIGIN Under the penalties of perjury, I swear that the above information is complete and accurate to the best of my personal knowledge. DATE SIGNED SIGNATURE OF JUDGMENT DEBTOR X Pursuant to Uniform Small Claims Rule 9(c), all information in this affidavit is CONFIDENTIAL. It shall be available to any other party to this litigation, but shall not be available for public inspection unless the Court so orders. DC-SC-6 (4/11) www.mass.gov/courts/districtcourt American LegalNet, Inc. www.FormsWorkFlow.com INCOME THAT IS EXEMPT FROM PAYMENT ORDERS 1. ALL INCOME FROM THE FOLLOWING SOURCES is exempt by law from any payment order: • Unemployment Benefits (G.L. c. 151A, § 36) • Workers Compensation Benefits (G.L. c. 152, § 47) • Social Security Benefits (42 U.S.C. § 401) • Federal Old-Age, Survivors & Disability Insurance Benefits (42 U.S.C. § 407) • Supplementary Security Income (SSI) for Aged, Blind & Disabled (42 U.S.C. § 1383[d][1]) • Other Disability Insurance Benefits up to $400 weekly (G.L. c. 175, § 110A) • Emergency Aid for Elderly & Disabled (now G.L. c. 117A) • Veterans Benefits Federal Veterans Benefits (38 U.S.C. § 5301[a]) Special Benefits for Certain WW II Veterans (42 U.S.C. § 1001) Medal of Honor Veterans Benefits (38 U.S.C. § 1562) State Veterans Benefits (G.L. c. 115, § 5) • Transitional Aid to Families with Dependent Children (AFDC) Benefits (G.L. c. 118, §10) • Maternal Child Health Services Block Grant Benefits (42 U.S.C. § 701) • Other public assistance benefits (G.L. c. 235, § 34, fifteenth) 2. In addition, A PORTION OF WAGES OR EMPLOYMENT-BASED RETIREMENT PAYMENTS is exempt by law from any payment order. The exempt amount is $400 or 85% of your weekly gross earnings, whichever is greater. Massachusetts law exempts the greater of 85% of the debtor’s gross earnings or 50 times the greater of the Federal minimum wage ($7.25 as of 7/24/09) or the Massachusetts minimum wage ($8.00 per G.L.c. 151, § 1) for each week or portion thereof. (G.L. c. 224, § 16 & c. 246, § 28). The Federal exemption (15 U.S.C. § §1671-1677) is not applicable as it will always be less than the Massachusetts exemption. DEFENDANT’S WORKSHEET FOR CALCULATING EXEMPT AMOUNT OF WAGES OR EMPLOYMENT-BASED RETIREMENT PAYMENTS Write the amount of your “weekly gross earnings” here = $ _____________ If your weekly gross earnings are less than $400, enter the amount of your weekly gross earnings ! If your weekly gross earnings are $400–$470, enter $400 ! If your weekly gross earnings are more than $470, enter 85% of your weekly gross earnings ! $ This is the amount of your weekly gross earnings that is exempt from any payment orders. DC-SC-6 (4/11) www.mass.gov/courts/districtcourt American LegalNet, Inc. www.FormsWorkFlow.com