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FINANCIAL STATEMENT OF JUDGMENT DEBTOR DOCKET NUMBER Trial Court of Massachusetts Small Claims Session CASE NAMECOURT DIVISION BOSTON MUNICIPAL COURT ________ Division DISTRICT COURT ________ Division HOUSING COURT ________ Division NAME OF JUDGMENT DEBTOR (the person who lost the case and owes money) HOME ADDRESSHOME TELEPHONE NUMBER DATE OF BIRTH SOCIAL SECURITY NUMBER DRIVER’S LICENSE NUMBER & STATE MARITAL STATUS NO. & AGE OF CHILDREN LIVING WITH YOU OCCUPATION EMPLOYER’S NAME & ADDRESS HOW LONG WITH EMPLOYER? Under the penalties of perjury, I swear that the above information is complete and accurate to the best of my personal knowledge. DATE SIGNED SIGNATURE OF JUDGMENT DEBTOR X INCOME (list all sources) Your Gross Pay: $ ........................ per week Your Take-Home Pay: $ ........................ per week Spouse’s Take-Home Pay: $ ........................ per week Child Support Income: $ ........................ per week Pension: $ ........................ per week AFDC/SSI: $ ........................ per week Other (itemize on back): $ ........................ per week Total Weekly Income: $ ........................ per week ASSETS (list value of all assets) Real Estate you own or co-own RESIDENCE OTHER Address: ............................................... Other Owner(s): ................................................ Mortgage Balance: $ .................. $ .................. Fair Market Value: $ .................. $ .................. Rental Income: $ .................. $ .................. Vehicle(s)/Boat(s) You Own VEHICLE/BOAT 1 VEHICLE/BOAT 2 Year/Make & Model: ................................................ Purchase Year: ................................................ Purchase Price: $ .................. $ .................. Amount Owed: $ .................. $ .................. Bank Accounts CHECKING SAVINGS Bank/Credit Union: ................................................ Account No.: ................................................ Balance: $ ....................... $ .................. Expected Tax Refund: $ ............................................... How much money do you have in cash? $ ................................ Have you disposed of or transferred any asset since this claim was brought? (If so, explain on back.)  No  Ye s (List on back anything of value not listed above that you own or co-own, or that is held for you by another.) EXPENSES Rent/Mortgage: $ ........................ per week Utilities: $ ........................ per week Food: $ ........................ per week Alimony/Child Support: $ ........................ per week Child Care: $ ........................ per week Transportation: $ ........................ per week Insurance: $ ........................ per week Entertainment (including cable): $ ........................ per week Other (itemize on back): $ ........................ per week Total Weekly Expenses: $ ........................ per week DEBTS (list all debts not included above in your expenses – e.g., credit card debts) CREDITOR NATURE OF DEBT DATE OF ORIGIN TOTAL DUE WEEKLY PAYMENT 1 .............................................................................................................................................. $ ...................... $ .................... 2 .............................................................................................................................................. $ ...................... $ .................... 3 .............................................................................................................................................. $ ...................... $ .................... Pursuant to Uniform Small Claims Rule 9(c), all information in this affidavit is CONFIDENTIAL.It shall be available to any other party to this litigation, but shall not be available for public inspection unless the Court so orders. This document was developed under Grant 11-T-162 of the State Justice Institute. The form does not necessarily represent the official position or policies of the State Justice Institute. Financial Statement of Judgment Debtor English 08/2012 www.mass.gov/courts/forms Rev. 08/ 17 INCOME AND PROPERTY THAT ARE EXEMPT FROM PAYMENT ORDERS (This list of exempt income and property is not comprehensive. It is provided to assist the court in avoiding the issuance of orders that would require payment from exempt sources. When requesting a payment order , the creditor bears the burden of proving that the debtor has sufficient non -exempt income or property with which to satisfy the judgment. See G.L. c. 224, § 16. ) 1. INCOME FROM THE FOLLOWING SOURCES is exempt by law from payment orders:  Unemployment Benefits (G.L. c. 151A, § 36)  Workers Compensation Benefits (G.L. c. 152, § 47)  Social Security Benefits (42 U.S.C. § 401)  Federal Old-Age, Survivors & Disability Insurance Benefits (42 U.S.C. § 407)  Supplementary Security Income (SSI) for Aged, Blind & Disabled (42 U.S.C. § 1383[d][1])  Other Disability Insurance Benefits up to $400 weekly (G.L. c. 175, § 110A)  Emergency Aid for Elderly & Disabled (G.L. c. 117A)  Veterans Benefits  Federal Veterans Benefits (38 U.S.C. § 5301[a])  Special Benefits for Certain WW II Veterans (42 U.S.C. § 1001)  Medal of Honor Veterans Benefits (38 U.S.C. § 1562)  State Veterans Benefits (G.L. c. 115, § 5)  Transitional Aid to Families with Dependent Children (AFDC) Benefits (G.L. c. 118, § 10)  Maternal Child Health Services Block Grant Benefits (42 U.S.C. § 701)  Other public assistance benefits (G.L. c. 235, § 34, cl. fifteenth)  Payouts from certain Massachusetts employee pension plans (G.L. c. 32, § 19) 2. Certain PERSONAL AND REAL PROPERTY is also exempt from payment orders, including:  $2,500 in cash or savings or other deposits in a banking or investment institution (G.L. c. 235, § 34, cl. fifteenth)  Automobile or vehicle up to exemption limit (G.L. c. 235, § 34, cl. sixteenth)  Other specific types of personal property are exempt under other clauses of G.L. c. 235, § 34  Real estate subject to automatic or declared homestead exemption (G.L. c. 188) and, in lieu thereof, the amount of money necessary for rent, up to $2,500 per month (G.L. c. 235, § 34, cl. fourteenth)  There are also exemptions for “aggregate” amounts, up to maximum limits, of certain unused exemptions (G.L. c. 235, § 34, cl. seventeenth) 3. In addition, A PORTION OF WAGES AND CONTRIBUTIONS TO EMPLOYMENT- BASED RETIREMENT PLANS is exempt by law from payment orders. Massachusetts law exempts the greater of 85% of the debtor’s gross earnings or 50 times the greater of the Federal minimum wage ($7.25 as of 7/24/09) or the Massachusetts minimum wage ($10/hr. until 12/31/16 per G.L. c. 151, § 1; and $11/hr. as of 1/1/17) for each week or portion thereof. (G.L. c. 224, § 16 & c. 235, § 34, cl. fifteenth). The amount exempt under federal law (15 U.S.C. § §1671-1677) may exceed the Massachusetts exemption. If so, the federal exemption applies. See Worksheet for Computing Amount of Wages Exempt From Attachment, Execution and Payment Orders. http://www.mass.gov/courts/docs/forms/small-claims/translated/english/ exemption-worksheet.pdf