This video is intended only to provide general legal information about how to fill out a Short Form Financial Statement.
The information in this video is not intended to be relied upon as legal advice. For legal advice you should consult an attorney.
By continuing with this video, you are agreeing to the statement above.
All Questions in this section must be answered. Do not leave any blank lines and do not write N/A. If a line does not apply to you, simply put a zero.
This section is intended to share basic information about you, where you live, and where you work.
In the top left corner, under “Division.” Choose the county where your case is. If this is the first time filing a case, choose the county where you expect to file your case.
On the top right corner of the form, write the complete docket number that the Court has assigned your case. If this is a new case and you do not yet have a docket number, leave that space blank.
Under the section marked “Instructions”, write the parties’ names. Often, people wonder which party to list first.
If you filed the case, you are the “Plaintiff”. If you did not start the case, you are the “Defendant”.
If you filed the case together, then you are “Petitioners“. Write your name on either line.
Part 1: Personal Information
Your Name: Write your full legal name; If you go by a different name, write AKA after your name and include the other name you use
Social Security: You may write xxx-xx-last four digits of your Social Security Number, if you have one.
Important: If any of your information, such as your address, your telephone number or information about where you work is impounded (meaning kept secret by the Court) or you plan to ask the Court to impound or hide any of that information because you believe disclosing this information would put you or your children at risk of harm, do not write the information on this form unless the Court orders otherwise. Instead, write “REQUESTING IMPOUNDMENT” or “IMPOUNDED”.
The following instructions apply only if the following information is not impounded or you do not plan to ask the Court to impound it:
Address: Write your street address, city or town, state and zip code. If you have a different mailing address, please add that information to the form.
Telephone Number: Write your telephone number.
Date of Birth: Write the month, day and year of your birth: Example: September 1, 2000.
Number of Children Living with You: Write the total number of children who are living with you and are dependent upon you for your support. This may include children who are not related to your particular case.
Occupation: Write the title of your job or what you do for work. If you are a homemaker, unemployed, or disabled write that here.
Name of Employer and Employer’s Address: Write your employer’s name, street address, city or town, state and zip code, if you are employed.
Employer’s Telephone Number: Write the telephone number of your employer, if you are employed.
Health Insurance: Check the box to answer “yes or no”
If your answer is Yes, write the name of your Health Insurance Provider. Examples of this are MassHealth, Tufts, Blue Cross/Blue Shield