Form JV-33 "Financial Statement (Short Form)" - Massachusetts

What Is Form JV-33?

This is a legal form that was released by the Trial Court of Massachusetts - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2007;
  • The latest edition provided by the Trial Court of Massachusetts;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form JV-33 by clicking the link below or browse more documents and templates provided by the Trial Court of Massachusetts.

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Commonwealth of Massachusetts
The Trial Court
Juvenile Court Department
_________________ Division
Docket No. _______________
FINANCIAL STATEMENT
(SHORT FORM)
____________________________________________ v ___________________________________________
Plaintiff
Defendant
Instructions: If your income equals or exceeds $75,000.00 you must complete the LONG FORM financial statement, unless
otherwise ordered by the Court. All questions on both sides of this form must be answered in full or the word “none” inserted.
If additional space is needed for any answer, an attached sheet may be filed in addition to, but not in lieu of, the answer.
1.
Gross W eekly Incom e
a)
Base pay from salary, wages
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
b)
Self Employment Income (attach a completed Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
c)
Income from overtime-commissions-tips-bonuses-part-time job . . . . . . . . . . . . . . . . . . . . . . .
$ _________
d)
Dividends - Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
e)
Income from trusts or annuities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
f)
Pensions and retirement funds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
h)
Disability, unemployment insurance or worker’s compensation
. . . . . . . . . . . . . . . . . . . . . . .
$ _________
i)
Public Assistance (welfare, A.F.D.C. payments) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
j)
Rental from Income Producing Property (attach a completed Schedule B)
. . . . . . . . . . . . . .
$ _________
k)
All other sources (including child support, alimony)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
l) Total Gross Weekly Income (a through k)
$ _________
2.
Item ize Deductions from Gross Income
a)
Federal income tax deductions (claiming _________ exemptions)
. . . . . . . . . . . . . . . . . . . .
$ _________
b)
State income tax deductions (claiming _________ exemptions)
. . . . . . . . . . . . . . . . . . . . . .
$ _________
c)
F.I.C.A./Medicare
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
d)
Medical Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
e)
Union Dues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
$ _________
f) Total Deductions (a through e)
3.
Adjusted Net W eekly Incom e
2(I) minus 2(f)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
4.
Other Deductions from Salary
a)
Credit Union (Loan Repayment or Savings) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
b)
Savings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
c)
Retirement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
d)
Other - Specify (such as Deferred Compensation or 401(K)__________________________
$ _________
e) Total Deductions (a through d)
$ _________
5.
Net Weekly Income
$ _________
3 minus 4(e) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.
Gross Yearly Income Prior Year
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
(attach copy of all W-2 and 1099 forms per prior year)
7.
W eekly Expenses (Do Not Duplicate W eekly Expenses - Strike Inapplicable W ords)
a)
Rent-Mortgage (PIT)
$ _________
g)
W ater/Sewer
$__________
b)
Homeowner/Tenant Insurance
$ _________
h)
Food
$ _________
c)
Maintenance and Repair
$ _________
i)
Uninsured Medicals
$ _________
d)
Heat (Type________)
$ _________
j)
House Supplies
$ _________
e)
Electricity and/or Gas
$ _________
k)
Laundry and Cleaning
$ _________
f)
Telephone
$ _________
l)
Clothing
$ _________
JV-33 (06/07)
(over)
Commonwealth of Massachusetts
The Trial Court
Juvenile Court Department
_________________ Division
Docket No. _______________
FINANCIAL STATEMENT
(SHORT FORM)
____________________________________________ v ___________________________________________
Plaintiff
Defendant
Instructions: If your income equals or exceeds $75,000.00 you must complete the LONG FORM financial statement, unless
otherwise ordered by the Court. All questions on both sides of this form must be answered in full or the word “none” inserted.
If additional space is needed for any answer, an attached sheet may be filed in addition to, but not in lieu of, the answer.
1.
Gross W eekly Incom e
a)
Base pay from salary, wages
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
b)
Self Employment Income (attach a completed Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
c)
Income from overtime-commissions-tips-bonuses-part-time job . . . . . . . . . . . . . . . . . . . . . . .
$ _________
d)
Dividends - Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
e)
Income from trusts or annuities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
f)
Pensions and retirement funds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
h)
Disability, unemployment insurance or worker’s compensation
. . . . . . . . . . . . . . . . . . . . . . .
$ _________
i)
Public Assistance (welfare, A.F.D.C. payments) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
j)
Rental from Income Producing Property (attach a completed Schedule B)
. . . . . . . . . . . . . .
$ _________
k)
All other sources (including child support, alimony)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
l) Total Gross Weekly Income (a through k)
$ _________
2.
Item ize Deductions from Gross Income
a)
Federal income tax deductions (claiming _________ exemptions)
. . . . . . . . . . . . . . . . . . . .
$ _________
b)
State income tax deductions (claiming _________ exemptions)
. . . . . . . . . . . . . . . . . . . . . .
$ _________
c)
F.I.C.A./Medicare
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
d)
Medical Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
e)
Union Dues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
$ _________
f) Total Deductions (a through e)
3.
Adjusted Net W eekly Incom e
2(I) minus 2(f)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
4.
Other Deductions from Salary
a)
Credit Union (Loan Repayment or Savings) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
b)
Savings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
c)
Retirement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
d)
Other - Specify (such as Deferred Compensation or 401(K)__________________________
$ _________
e) Total Deductions (a through d)
$ _________
5.
Net Weekly Income
$ _________
3 minus 4(e) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.
Gross Yearly Income Prior Year
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________
(attach copy of all W-2 and 1099 forms per prior year)
7.
W eekly Expenses (Do Not Duplicate W eekly Expenses - Strike Inapplicable W ords)
a)
Rent-Mortgage (PIT)
$ _________
g)
W ater/Sewer
$__________
b)
Homeowner/Tenant Insurance
$ _________
h)
Food
$ _________
c)
Maintenance and Repair
$ _________
i)
Uninsured Medicals
$ _________
d)
Heat (Type________)
$ _________
j)
House Supplies
$ _________
e)
Electricity and/or Gas
$ _________
k)
Laundry and Cleaning
$ _________
f)
Telephone
$ _________
l)
Clothing
$ _________
JV-33 (06/07)
(over)
m)
Life Insurance
$ _________
q)
Motor Vehicle Loan
$ _________
n)
Medical Insurance
$ _________
r)
Child Care
$ _________
o)
Incidentals and Toiletries
$ _________
s)
Other (specify)
$ _________
p)
Motor Vehicle Expenses
$ _________
________________________________
$ _________
$ _________
Total W eekly (a through s)
8.
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 expenses to prosecute action $ ______ to $ ________
9.
Assets (Attach additional schedule for additional real estate and other assets, if necessary)
a)
Real Estate
Location ___________________________________________________________________
Title held by ________________________________________________________________
$ _________
Fair market value $ _______________ - Mortgage $ _________________
= Equity
b)
$ _________
IRA, Keogh, Pension, Profit Sharing, Other Retirement Plans ______________________
$ _________
__________________________________________________________________________
$ _________
__________________________________________________________________________
c)
$ _________
Tax Deferred Annuity Plan(s) _________________________________________________
d)
$ _________
Life Insurance: Present Cash Value ___________________________________________
e)
Savings & Checking Accounts, Money Market Accounts and CDs - 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). List Financial Institution Name and Account Numbers
$ _________
_________________________________________________________________________
$ _________
_________________________________________________________________________
f)
Motor Vehicles
$ _________
Fair Market Value $________________ Motor Vehicle Loan $_____________
= Equity
$ _________
Fair Market Value $________________ Motor Vehicle Loan $_____________
= Equity
g)
$ _________
Other (such as - stocks, bonds, collections)____________________________________
$ _________
_________________________________________________________________________
$ _________
_________________________________________________________________________
$ _________
h) Total Assets (a through g)
11.
Liabilities: Creditor
Nature of
Date of Origin
Amount Due
W eekly Payment
Debt
a)
$
$
b)
c)
d)
Total Amount Due and Total Weekly Paym ent
$
$
12.
Number of Years you have paid Social Security
__________ years
I certify under the penalties of perjury that my income and expenses, assets, and liabilities as stated herein are true to the best
of my knowledge and belief. I have carefully read this financial statement and I certify the information is true and complete.
Signature _______________________________________________________
Date ____________________________
STATEMENT OF ATTORNEY
I, the undersigned attorney, am admitted to practice law in the Commonwealth of Massachusetts - am admitted pro hac 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.
Attorney’s Signature_______________________________________________
Date ____________________________
Address _________________________________________________________ Telephone No.(_____)______________
B.B.O. No. _____________________________________________
WRITE “NONE” ON ANY LINE THAT DOES NOT APPLY TO YOU.
DO NOT LEAVE ANY LINES BLANK
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