How to Fill Out a Financial Statement

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What Is a Financial Statement?

All Probate and Family Courts require you to fill out a Financial Statement if you are a party in a case and your case involves money, such as in a case involving child support or alimony. The purpose of this form is for you to explain your financial situation to the court. The court has a Short Form Financial Statement and a Long Form. Use the Short Form if your gross income (income before taxes and any deductions) is less than $75,000 per year. Filing a Financial Statement should not be taken lightly. You must tell the truth about all of your income and expenses. This booklet will help you fill out a Financial Statement (Short Form), answer some basic questions about what to include, and give you practical tips that will hopefully make it easier for you to complete this form.

Don't Wait Until the Last Minute

Do not wait until the last minute or until you are in court to fill out a Financial Statement. If you do, you could make mistakes because you are rushed or you may not have all of the information you need. To get a Financial Statement form, go to the Register's Office at the Probate and Family Court. The form itself is on pink paper. You will need to fill this form out before your first hearing. Because you will have a lot of adding, subtracting, and dividing to do to complete the form, we strongly recommend using a calculator. If you do not have one, you may be able to borrow one or buy a very inexpensive one.

How to Use This Booklet

This booklet is written so that it corresponds to the different sections and letters on the Financial Statement. We do not go over how to fill out every line because in many cases the form speaks for itself. The information provided here covers just the areas of the form where you might have questions. For example, in Part 2 we skip from line (b) to line (g) because it is not necessary to cover lines (c), (d), (e), and (f).

What Information Must You Include?

You must fill in every line of the form. If something does not apply to you, write "zero" or "none." If you run out of space on any item, attach a separate sheet of paper. What follows are more detailed instructions about how to fill out the Financial Statement.

Documents That Will Help you Complete a Financial Statement

Pay stubs for the past 12 months, if you have a salary.
Gas and electric bills for the past 3 months.
Telephone bills, for the past 3 months.
Most recent mortgage statement, deed or other document that states date of purchase, purchase price and lot number, if you own a house or land.
Tax returns for the last year.

Top of the Form

Write your county on the line next to Division. Fill in the Docket Number. This is the number that the court has assigned to your case. If you do not know it, ask the clerk. Fill in the names of the Plaintiff and the Defendant. The Plaintiff is the person bringing the case to court. The Defendant is the person whom the case is against.

Part 1: Personal Information

Fill in all of the information requested. If your address is impounded (protected by the court) or listing it would put you or your children in danger, do not write your address on the Financial Statement. See Information About How to File Papers in Essex Probate and Family Court.

Part 2: Gross Weekly Income for All Sources

Here you need to provide information about your weekly income before taxes are taken out.

Base pay from salary and wages: Give your current salary. If your salary changes from paycheck to paycheck, give the average amount for the past 3 months.
Self-Employment Income: If you are self-employed or own a business, you must fill out and attach a form called "Schedule A, Monthly Self-Employment or Business Income." This form is available at the court.
Social Security: This is for Social Security Retirement payments (OASDI).
Disability: This is for Supplemental Security Income (SSI), unemployment insurance, or worker's compensation.
Public Assistance: This includes TAFDC, EAEDC, and Food Stamps.
Rental Income: If you get income from rental property, you must fill out and attach a form called "Schedule B, Rent from Income-Producing Property." This form is available at the court.
All other sources: This includes child support payments, alimony, and any other income not listed in (a) through (j). Again, if these payments change from time to time, figure out the average weekly amount.
Total Gross Weekly Income: Add together all of your income in lines a to k.

Part 3: Itemize Deductions from Gross Income

Here you need to provide your weekly deductions from gross income.

(a) & (b) If you get a salary, your pay stubs should list federal and state tax deductions.
(c) If you get a salary, check your pay stub to see how much FICA is taken out. There may also be a separate Medicare deduction on your pay stub. If there is, add the FICA and Medicare together, figure out what the weekly amount of FICA + Medicare is, and put this number on line (c).
- If the amount of FICA is different on your pay stubs over the past year, you need to figure out the average weekly amount by adding up all FICA deductions over the past 12 months and dividing the total by 52.
- If you have not been getting a paycheck for a full year, add all the FICA amounts you've received, count the number of weeks you've received paychecks, and divide the total FICA amount by that number of weeks.
(f) Add together all deductions in lines (a) to (e).

Part 4: Adjusted Net Weekly Income

Subtract line 3(f) from line 2(l) to get your adjusted net weekly income.

Part 5: Other Deductions from Salary

Here you need to provide information about the weekly amount of all other deductions that come out of your salary.

Part 6: Net Weekly Income

Subtract line 5(e) from line 4 to get your net weekly income.

Part 7: Gross Yearly Income from Prior Year

Here you need to provide your gross yearly income (before taxes) from the prior year. Add up all your paychecks for the last calendar year. If you received TAFDC in the last year, multiply the amount on your check (which comes twice a month) by 24 to get your total for the last calendar year. You must also attach a copy of all W-2 and /or 1099 Forms for the prior year.

Part 8: Weekly Expenses

Read through all the categories (a-s) and think about what you will put under each category. The most important thing is to pick only one category to put an expense under and not list it twice. Again, you must fill in the weekly amounts.

(d) & (e) If you have gas heat and you also have other items on your gas bill (stove, dryer, etc...), try to estimate how much of the bill is for heat and put that on line (d) and how much is for other gas charges and put that on line (e).

(f) Put the average telephone bill by adding up the last 3 months of bills and dividing by 13. (g) List water and sewer amounts if you pay for them. If not, write "none".

(i), (j), & (o) House supplies, laundry and cleaning, and incidental and toiletries are very similar categories. Make sure you list each item in only one category. For example:

(i) House supplies = light bulbs, batteries, toilet paper.
(j) Laundry and cleaning = laundromat costs, detergent, cleaning supplies
(o) Incidentals and toiletries = toothpaste, makeup

(k) You will need to provide an average weekly amount you spend on clothing by figuring out how much you spend for the whole year and dividing that by 52. People often buy a few big ticket items over the course of a year, such as new school clothes for children, winter coats and boots for children, clothes for yourself during the year.

(n) If you have medical insurance, in this line you should document how much you have paid out-of-pocket in co-payments and deductibles that your insurance did not cover. This includes dental care, therapy, medicine (such as cough medicine, aspirin, vitamins). If you do not have medical insurance, this line should reflect all of your medical expenses. Again, you must figure out the weekly average amount).

(p) These are repairs and maintenance costs for your car, which include garage costs and gas. This does not include auto loan payments, which go on the next line.

(q) This means auto loan payments.

(r) This includes regular child care and additional babysitting.

(s) Other can include (but is not limited to):

Other expenses not already included

Restaurants
Cable
Vacation
Public Transportation
Membership Dues
Entertainment

Part 10: Assets

(a) Real Estate: This refers to any house or land that you own, either alone or jointly with your spouse or anyone else.

Next to location, list the address.

Next to title, list the book and page number of the deed for the property.

Next to Fair Market Value, give your best estimate as to the price that you could get for it if you sold it today. Write on the form that this is an estimate. If you can not estimate the Fair Market Value, give the purchase price and write on the form that this was the purchase price.

Next to Mortgage, list the unpaid balance on the mortgage.

Next to Equity, subtract the Mortgage from the Fair Market Value. If the answer is a negative number, make sure to put a minus sign before the number.

(f) Give the Fair Market Value of each automobile that you or your spouse own and indicate whose possession it is in. The Fair Market Value is the price that you could get for the car if you sold it today. List the amount unpaid on any car loan. Subtract the amount unpaid on the loan from the Fair Market Value to get the Equity.

(g) List any other personal property that is either in your possession or your spouse's possession, such as: furniture, jewelry, boats, collections, firearms, recreational vehicles, silver, stereo equipment, and tools. For any item over $500 describe it specifically. If the property is in your spouse's possession, indicate that on the form. To estimate the value of your furniture, estimate what you would charge if you sold the entire contents of your home today. This is a rough estimate.

Part 11: Liabilities

Here you must list all of your debts. For each debt you must list:

Name of the person or institution you owe the money to (creditor),
Nature of the debt (for example, personal loan, doctor's visit, car loan, household items),
Date that you first incurred the debt (date of origin),
Total amount due, and
How much you are paying or planning to pay on a weekly basis.
(e) Here you must add up the total amount of the debts and put this on the first line. Then figure out what the total amount of the weekly payments for your debts would be and put this on the second line. If you have been unable to make the payments, write "0" or "none."

Part 12: Number of Years You Have Paid into Social Security

Here you must put the number of years that you've earned money through work and paid social security.

What Do You Do After You Complete the Form?

Sign the form. The words saying "I certify under penalties of perjury" mean that all the information you have provided is true. This is very important. If you do not tell the truth, a judge can take certain actions to punish you.
If you are representing yourself, write "pro se" in the blank next to "Attorney's Signature."
Provide your address and telephone number. If it is impounded (protected by the court) or listing it would put you or your children in danger, then do not write your address or phone number down.
Make two copies of the form.
File the original form with the clerk at the Probate and Family Court before or at the time you request a hearing.
Keep one copy for yourself so that if the court asks you questions you can look at it.
Give the other copy to the other party. You are required to do this. Likewise, the other party is required to provide you with a copy of his or her Financial Statement.
Once both parties have filled out the financial statement, you can calculate what child support should be by filling in the child support guidelines worksheet.