Fillable Commonwealth of Massachusetts Financial Statement

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Commonwealth of Massachusetts Financial Statement

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The Commonwealth of Massachusetts Financial Statement form is 2 pages long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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FINANCIAL STATEMENT
......................................................................
Name Date of Birth Social Security Number
......................................................................
Address Telephone Number
......................................................................
Employer Employer’s Address
......................................................................
Position held Employer’s Telephone Number
If unemployed:
How long.............Why .............................................
Previous Employer ..............................Position .............
Physical or mental disability ........................................
Income
Gross Pay $..............,weekly $....................last year
Net Pay $................weekly $....................per month
Social Security, pension, retirement income $..............per month
Unemployment disability, worker’s compensation $...........per month
Public assistance (Welfare, AFDC, SSI, VA) $...............per month
Child support or alimony income $...........weekly $.......per month
Other income $.......................Source ..........................
......................................................................
Assets
Property owned .................................Value $...............
P.I.T. payments $..............................Bal. Due $.............
Name of Bank ..................................Mtg. Bal.$.............
Car .....................Year and make .............Value $...........
Bank accounts .....Checking $..............Savings $..................
Names of banks .......................................................
......................................................................
Other assets
.........................................................
......................................................................
......................................................................
......................................................................
0.00
0.00
0.00
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2
Liabilities
......................................................................
......................................................................
......................................................................
......................................................................
Current Income and Expenses (from all sources)
Gross (weekly) (monthly) income $ ...............................
Federal tax ..........................
State tax ............................
Social Security ......................
Health Insurance .....................
Pension ..............................
Other ................................
......................................
......................................
......................................
Total Deductions $.........................
Net (weekly) (monthly) income $ .................
Rent $................................
Heat $................................
Gas $ ................................
Electric $ ...........................
Food $ ...............................
Clothing $ ...........................
Other $ ..............................
......................................
......................................
Total Expenses $............................
Net Income minus expenses $ .....................
Persons Living with you: .............................................
Other facts relevant to ability to pay: ..............................
......................................................................
......................................................................
......................................................................
Signed under the penalties of perjury:
______________________________________
Name: ________________________________
Address: _____________________________
______________________________________
Telephone No. ________________________
Date: ................
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Commonwealth of Massachusetts Financial Statement

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Completed 21 May 2020

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