Fill and Sign the New York Appellate Practice Nysba Form

Commonwealth of MassachusettsThe Trial CourtJuvenile Court Department_________________ DivisionDocket No. _______________FINANCIAL STATEMENT(SHORT FORM)____________________________________________ v ___________________________________________Plaintiff DefendantInstructions: If your income equals or exceeds $75,000.00 you must complete the LONG FORM financial statement, unlessotherwise ordered by the Court. All questions on both sides of this form must be answered in full or the word “none” inserted.If additional space is needed for any answer, an attached sheet may be filed in addition to, but not in lieu of, the answer. 1.Gross Weekly Incomea)b)c)d)e)f)h)i)j)k)Base pay from salary, wages .................................................Self Employment Income (attach a completed Schedule A) ..........................Income from overtime-commissions-tips-bonuses-part-time job .......................Dividends - Interest .........................................................Income from trusts or annuities ................................................Pensions and retirement funds ................................................Disability, unemployment insurance or worker’s compensation .......................Public Assistance (welfare, A.F.D.C. payments) ...................................Rental from Income Producing Property (attach a completed Schedule B) ..............All other sources (including child support, alimony) ................................$ _________$ _________$ _________$ _________$ _________$ _________$ _________$ _________$ _________$ _________l) Total Gross Weekly Income (a through k)$ _________2.Itemize Deductions from Gross Incomea)b)c)d)e)Federal income tax deductions (claiming _________ exemptions) ....................State income tax deductions (claiming _________ exemptions) ......................F.I.C.A./Medicare ..........................................................Medical Insurance ..........................................................Union Dues ...............................................................$ _________$ _________$ _________$ _________$ _________f) Total Deductions (a through e)$ _________3.Adjusted Net Weekly Income2(I) minus 2(f) .................................................................$ _________4.a) b) c) d) Other Deductions from SalaryCredit Union (Loan Repayment or Savings) ......................................Savings...................................................................Retirement ................................................................Other - Specify (such as Deferred Compensation or 401(K)__________________________$ _________$ _________$ _________$ _________e) Total Deductions (a through d)$ _________5.Net Weekly Income 3 minus 4(e) ...................................................................$ _________6.Gross Yearly Income Prior Year .................................................(attach copy of all W-2 and 1099 forms per prior year)$ _________7.Weekly Expenses (Do Not Duplicate Weekly Expenses - Strike Inapplicable Words)a)Rent-Mortgage (PIT)$ _________g)Water/Sewer$__________b)Homeowner/Tenant Insurance$ _________h)Food$ _________c)Maintenance and Repair$ _________i)Uninsured Medicals$ _________d)Heat (Type________)$ _________j)House Supplies$ _________e)Electricity and/or Gas$ _________k)Laundry and Cleaning$ _________f)Telephone $ _________l)Clothing$ _________JV-33 (06/07) (over) m)Life Insurance$ _________q)Motor Vehicle Loan$ _________n)Medical Insurance$ _________r)Child Care$ _________o)Incidentals and Toiletries$ _________s)Other (specify)$ _________p)Motor Vehicle Expenses$ _________________________________________$ _________Total Weekly (a through s)$ _________8.a)b)c)Counsel FeesRetainer amount(s) paid to your attorney(s) ......................................Legal Fees incurred to date, against retainer(s) ...................................Anticipated range of total legal expenses to prosecute action $ ______ to $ ________$ ________$ ________9.a)b)c)d)e)f)g)Assets (Attach additional schedule for additional real estate and other assets, if necessary)Real EstateLocation ___________________________________________________________________Title held by ________________________________________________________________Fair market value $ _______________ - Mortgage $ _________________ = EquityIRA, Keogh, Pension, Profit Sharing, Other Retirement Plans __________________________________________________________________________________________________________________________________________________________________________Tax Deferred Annuity Plan(s) _________________________________________________Life Insurance: Present Cash Value ___________________________________________Savings & Checking Accounts, Money Market Accounts and CDs - which are heldindividually, jointly, in the name of another person for your benefit, or held by you for thebenefit of your minor child(ren). List Financial Institution Name and Account Numbers__________________________________________________________________________________________________________________________________________________Motor Vehicles Fair Market Value $________________ Motor Vehicle Loan $_____________ = EquityFair Market Value $________________ Motor Vehicle Loan $_____________ = EquityOther (such as - stocks, bonds, collections)______________________________________________________________________________________________________________________________________________________________________________________ h) Total Assets (a through g)$ _________$ _________$ _________$ _________$ _________$ _________$ _________$ _________$ _________$ _________$ _________$ _________$ _________$ _________11.Liabilities: CreditorNature ofDebtDate of OriginAmount DueWeekly Paymenta)$$b)c)d)Total Amount Due and Total Weekly Payment $$12.Number of Years you have paid Social Security __________ yearsI certify under the penalties of perjury that my income and expenses, assets, and liabilities as stated herein are true to the bestof my knowledge and belief. I have carefully read this financial statement and I certify the information is true and complete. Signature _______________________________________________________Date ____________________________STATEMENT OF ATTORNEYI, the undersigned attorney, am admitted to practice law in the Commonwealth of Massachusetts - am admitted pro hac vice forthe purposes of this case – and am an officer of the court. As the attorney for the party on whose behalf this Financial Statementis submitted, I hereby state to the court that I have no knowledge that any of the information contained herein is false. Attorney’s Signature_______________________________________________Date ____________________________Address _________________________________________________________Telephone No.(_____)______________B.B.O. No. _____________________________________________WRITE “NONE” ON ANY LINE THAT DOES NOT APPLY TO YOU. DO NOT LEAVE ANY LINES BLANK