Free Housing Court Financial Statement - Massachusetts

FINANCIAL STATEMENT

...................................................................... Name Date of Birth Social Security Number ...................................................................... Address Telephone Number ...................................................................... Employer Employer's Address ...................................................................... Position held Employer's Telephone Number If unemployed: How long.............Why ............................................. Previous Employer ..............................Position ............. Physical or mental disability ........................................ Income Gross Pay $..............,weekly $....................last year Net Pay $................weekly $....................per month Social Security, pension, retirement income $..............per month Unemployment disability, worker's compensation $...........per month Public assistance (Welfare, AFDC, SSI, VA) $...............per month Child support or alimony income $...........weekly $.......per month Other income $.......................Source .......................... ...................................................................... Assets Property owned .................................Value $............... P.I.T. payments $..............................Bal. Due $............. Name of Bank ..................................Mtg. Bal.$............. Car .....................Year and make .............Value $........... Bank accounts .....Checking $..............Savings $.................. Names of banks ....................................................... ...................................................................... Other assets ......................................................... ...................................................................... ...................................................................... ......................................................................

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Liabilities ...................................................................... ...................................................................... ...................................................................... ...................................................................... Current Income and Expenses (from all sources) Gross (weekly) (monthly) income $ ............................... Federal tax .......................... State tax ............................ Social Security ...................... Health Insurance ..................... Pension .............................. Other ................................ ...................................... ...................................... ...................................... Total Deductions $......................... Net (weekly) (monthly) income $ ................. Rent $................................ Heat $................................ Gas $ ................................ Electric $ ........................... Food $ ............................... Clothing $ ........................... Other $ .............................. ...................................... ...................................... Total Expenses $............................ Net Income minus expenses $ ..................... Persons Living with you: ............................................. Other facts relevant to ability to pay: .............................. ...................................................................... ...................................................................... ...................................................................... Signed under the penalties of perjury: ______________________________________ Name: ________________________________ Address: _____________________________ ______________________________________ Telephone No. ________________________ Date: ................