Percy, Tedeschi & Associates, P.C. Attorneys and Counselors at Law

How to Complete a Financial Statement

• Use the short form Financial Statement only if your gross yearly income (before taxes and other deductions) is less than $75,000.00.
• Use the long form Financial Statement if your gross yearly income is more than $75,000.00.
• If you are self-employed you must complete Schedule A.
• If you own any rental property, you must complete Schedule B.

The Financial Statement should be completed truthfully and accurately. For the Short Form Financial Statement, please follow the instructions listed below:

1. Fill in your name, social security number, address, age, telephone number, occupation, etc. If you are not working please print "unemployed" in the space provided for "employer".

2. Gross Weekly Income from All Sources:

   Fill in all your gross income (before any deductions). You must use weekly amounts. You should list only your income. If you are paid monthly, divide your monthly income by 4.3. If you are paid every two weeks, divide your income from each paycheck by 2. In Items 2(c) through 2(k) circle those items that apply to you. Write "none' on any line for which you have no income. It is helpful if you bring your most recent pay stub to Court along with the financial statement. If you are self-employed you should bring your tax return for the prior year, including Schedule C.

3. Itemize Deductions from Gross Income:

   Complete this section by listing the deductions from your paycheck. Use weekly amounts, dividing the same way you did for the income.

4. Adjusted Net Income:

   You should subtract your Total Deductions from line 3(f) from the Total Gross Weekly Income from Line 2(l).

5. Other Deductions from Salary:

   Complete this section by listing other deductions from your paycheck not listed in line 3 and put the total in line 5(e).

6. Net Weekly Income:

   You should subtract your Total Deductions Line 5(e) from Adjusted Net Weekly Income Line 4.

7. Gross Yearly Income from prior Year.

   You should write in your total income from last year's 1099 and W-2's forms. You should also attach copies of last year's 1099 and W-2's forms to the Financial Statement.

8. Weekly Expenses:

   You should complete this section by filling in your weekly expenses. To get weekly amounts you should divide your monthly expenses by 4.3. Please DO NOT list expenses here that you have listed as deductions from your paycheck in Sections 3 and Section 5 on Page 1 of the Financial Statement. However, you should include the weekly payments for any liabilities listed in Section 11. If someone else in your household pays some of the expenses, you should only write down the amount that you actually pay.

9. Counsel Fees.

   Complete this section by listing the amount that you have paid to any attorney and fees that you expect to pay to an attorney relative to your case. If you have an attorney, he or she can help you complete this section.

10. Assets:

    You should complete this section by listing any real estate you own, the location of the real estate, the names that are on the deed to the property, the fair market value and mortgage balance. The equity is derived by deducting the mortgage balance from the fair market value. You should then complete 10(b)-10(g) by listing any retirement plans, life insurance, bank accounts, pensions, motor vehicles, stocks and bonds and any other items of value you own. For savings, checking, etc. list the name of the bank and the account number then list the current balance in the appropriate line to the right. You should bring to Court copies of your most recent bank statements (checking and savings) together with copies of any retirement account statements and any other applicable account statements.

11. Liabilities:

    Complete this section by listing all of your debts. List the credit card name and/or person's name, the type of debt, when you first borrowed the money and the current balance due. If you make payments on the debt, list the weekly payment where applicable. You can divide the monthly payment by 4.3 to obtain the weekly payment.
12. Total number of years you have paid to Social Security: List the number of years you have contributed to social security since you began working.

Please do not forget to sign and date the form. If you have a lawyer, he or she must complete the "Statement By Attorney" section. The original Financial Statement should be filed with the Court. You should keep one copy for yourself and mail a copy to the other person in the case. If the other person has an attorney, mail the copy to the attorney.

Providing legal services throughout Massachusetts (MA, Mass) such as in Boston, Abington, Acushnet, Attleboro, Avon, Berkely, Braintree, Bridgewater, Brockton, Canton, Carver, Dartmouth, Dedham, Dighton, Dover, East Bridgewater, Easton, Fairhaven, Fall River, Foxboro, Franklin, Freetown, Hanson, Holbrook, Lakeville, Mansfield, Marion, Mattapoisett, Medfield, Middleborough, Milton, Needham, New Bedford, Norfolk, North Attleboro, Norton, Norwood, Pembroke, Randolph, Raynham, Plymouth, Quincy, Rehoboth, Rochester, Seekonk, Somerset, Stoughton, Swansea, Taunton, Walpole, Wareham, Wellesley, West Bridgewater, Westport, Westwood, Weymouth, Whitman, and Bristol County, Middlesex County, Norfolk County, Plymouth County, Suffolk County, South Coast, Boston Metro, Boston Metro South, Southeastern Mass, South Shore, and in Providence and all of Rhode Island (RI).