Use these instructions ONLY if:

A.You are the Plaintiff, Defendant or Petitioner in a Divorce,
Separate Support, Paternity, Modification or Contempt case or any
other case involving alimony, child support or division of


B. Your gross yearly income (before taxes and other deductions) is
less than $75,000.

You must complete the Long Form Financial Statement if your gross yearly income is more than $75,000.

If you work for yourself, you must also complete Schedule A.

If you own any rental property, you must also complete Schedule B.

As information is inserted on the Financial Statement, it self-calculates for your convenience.


  • The Financial Statement is one of the most important papers that you file with the Court. The judge will make important decisions based on the information that you write down.
  • Fill out the form completely and truthfully. Your signature indicates that the information you provide is true to the best of your knowledge. Since you are signing under the penalties of perjury, untrue statements can lead to criminal prosecution.
  • Each person in your case must file a completed Financial Statement within 45 days after the Plaintiff delivers the Complaint to the Defendant and at all court hearings involving alimony, child support, division of property or any other financial matters.
    For more information See Uniform Probate Court Practice XXX pdf format of Rules About Filing Financial Statements
and Supplemental Probate Court Rule 401 (Repealed effective January 2, 2012.)

Instructions for completing the Financial Statement (Short Form)

Fill in every line. If you have nothing to put on a line, write in the word “NONE”. If you need more space for the information in Sections 5, 8, 10 or 11, you may attach additional sheets of paper. The staff at the Registry of Probate can give you a sample, completed Financial Statement.

1. Personal Information. If you are not currently working, write “UNEMPLOYED” in the space where the form asks for “Employer”.

2. Gross Weekly Income/ Receipts from All Sources. Your gross income should reflect all income received before deductions. You must use weekly amounts. List only your income, not the income of other people involved in the case. If you are paid monthly, divide your monthly gross income by 4.3. If you are paid every two weeks, divide your gross income from each paycheck by 2. If you are paid twice a month, divide your gross income from each paycheck by 2.15. Write “NONE” on any line for which you have no income. It is helpful if you bring to court your most recent pay stub. If you are self-employed, bring last year’s tax return, including Schedule C and any other related forms.

3. Itemized Deductions from Gross Income. Fill in the deductions that appear on your paycheck. Use weekly amounts, dividing in the same way that you did for your gross income.

4. Adjusted Net Weekly Income. Subtract “Total Deductions” on line 3(f) from “Total Income” online 2(r).

5. Other Deductions from Salary/Wages. Fill in any other amounts deducted from your wages.

6. Net Weekly Income.  Subtract "Total Deductions" (line 5 (e)) from "Adjusted Net Weekly Income" (line 4).

7. Gross Yearly Income from Prior Year. Fill in your total income from last year before taxes or other deductions and attach copies of last year's W-2 and 1099 form(s) showing your income.

8. Weekly Expenses.  Fill in weekly amounts. Divide monthly amounts by 4.3 to get weekly amounts. Do NOT list expenses that you have listed as deductions from your pay in Section 3 or Section 5. Do 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. Write in the amounts that you have paid and that you expect to pay to an attorney. If you have an attorney, he or she can help you complete this section.

10. Assets. Fill in the present value of real estate, motor vehicles, retirement plans, life insurance, bank accounts, stocks and bonds and any other items of value you own. For savings, checking money market accounts, certificates of deposit list the name of the financial institution and the account number. You should bring to court the most recent statements for all accounts.

11. Liabilities. List all of your debts on the chart. List the creditor, the kind of debt, when you first borrowed the money (or the date that you were ordered to pay the money) and the current amount due. If your credit card “amount due” column represents multiple purchases made at different times please write “various dates” in the “date incurred” column. If you make payments on a liability, write “see weekly expenses” in “Weekly Payment” column and include the weekly amount in Section 8.

Do Not Forget To Sign and Date the form. If you have a lawyer, he or she must complete the “Statement By Attorney” on the back of the form. File the original with the court. Keep one copy and mail a copy to the other person in your case. If the other person has a lawyer, mail the copy to the lawyer.

Click here pdf format of Instructions for Financial Statement- Short Form
to form instructions in PDF format