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.
Paragraph 3. Itemized Deductions from Gross Income
Federal income tax deductions: This is the number of federal tax deductions you may have told your employer you could claim when you started your job and completed a W4 form. It is not necessarily the actual amount of deductions you claim when you file your federal taxes. The exemption information is typically found on your paystub but not always.
State income tax deductions: This is the number of state tax deductions you may have told your employer you could claim when you started your job and completed a W4 form. It is not necessarily the actual amount of deductions you claim when you file your state taxes. The exemption information is typically found on your paystub but not always.
You can also add in MA PFML and MA FML here. PFML and FML are mandatory paid leave pools that the state of MA requires both employees and employers to pay into these leave types. Remember that if you are paid anyway other than weekly, you will have to calculate a weekly amount for these numbers, too.
FICA and Medicare. FICA stands for Federal Insurance Contributions Act. It is more commonly referred to as “Social Security.” On your paycheck, it may also be listed as OASDI or SSA. Add this number together with the Medicare amount, which may be listed as Fed MED/EE. Remember that if you are paid anyway other than weekly, you will have to calculate a weekly amount for these numbers, too.
Medical Insurance. Do you get medical insurance through your work? If you do, you can write in the amount taken out of your check per week for health, vision, and dental health insurance here.
Union Dues. Are you part of a Union? If you are, write the amount taken out of your check for dues per week on this line.
Total Deductions. Add all of the amounts written on the lines in this section and write that number here.
Paragraph 4. Adjusted Net Weekly Income
In this section, you subtract your total deductions from paragraph 3 from your Total Gross Weekly Income/Receipts from the bottom line of the first page.