Massachusetts > Statewide > State District Court > Small Claims
Financial Statement Of Judgment Debtor DC-SC-6 - Massachusetts
| Financial Statement Of Judgment Debtor Form. This is a Massachusetts form and can be used in Small Claims State District Court Statewide . |
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FINANCIAL STATEMENT OF JUDGMENT DEBTOR CASE NAME DOCKET NUMBER Trial Court of Massachusetts Small Claims Session CURRENT COURT NAME OF JUDGMENT DEBTOR (the person who lost the case and owes money) HOME ADDRESS HOME 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? INCOME (list all sources) Your Gross Pay: Your Take-Home Pay: Spouse's Take-Home Pay: Child Support Income: Pension: AFDC/SSI: Other (itemize on back): Total Weekly Income: $ . . . . . . . . . . . . per week $ . . . . . . . . . . . . per week $ . . . . . . . . . . . . per week $ . . . . . . . . . . . . per week $ . . . . . . . . . . . . per week $ . . . . . . . . . . . . per week $ . . . . . . . . . . . . per week $ . . . . . . . . . . . . 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 EXPENSES Rent/Mortgage: Utilities: Food: Alimony/Child Support: Child Care: Transportation: Insurance: Other (itemize on back): Total Weekly Expenses: $ . . . . . . . . . . . per week $ . . . . . . . . . . . per week $ . . . . . . . . . . . per week $ . . . . . . . . . . . per week $ . . . . . . . . . . . per week $ . . . . . . . . . . . per week $ . . . . . . . . . . . per week $ . . . . . . . . . . . per week $ . . . . . . . . . . . per week 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.) 9 No 9 Yes (List on back anything of value not listed above that you own or co-own, or that is held for you by another.) Entertainment (including cable): $ . . . . . . . . . . . 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 ....................................................................... $........... $........... $........... $.......... $.......... $.......... 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 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. DC-SC-6 (4/11) www.mass.gov/courts/districtcourt American LegalNet, Inc. www.FormsWorkFlow.com INCOME THAT IS EXEMPT FROM PAYMENT ORDERS 1. ALL INCOME FROM THE FOLLOWING SOURCES is exempt by law from any payment order: · · · · · · · · 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 (now 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, fifteenth) 2. In addition, A PORTION OF WAGES OR EMPLOYMENT-BASED RETIREMENT PAYMENTS is exempt by law from any payment order. The exempt amount is $400 or 85% of your weekly gross earnings, whichever is greater. 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 ($8.00 per G.L.c. 151, § 1) for each week or portion thereof. (G.L. c. 224, § 16 & c. 246, § 28). The Federal exemption (15 U.S.C. § §1671-1677) is not applicable as it will always be less than the Massachusetts exemption. DEFENDANT'S WORKSHEET FOR CALCULATING EXEMPT AMOUNT OF WAGES OR EMPLOYMENT-BASED RETIREMENT PAYMENTS Write the amount of your "weekly gross earnings" here = If your weekly gross earnings are less than $400, enter the amount of your weekly gross earnings ! If your weekly gross earnings are $400$470, enter $400 ! If your weekly gross earnings are more than $470, enter 85% of your weekly gross earnings ! $ _____________ $ This is the amount of your weekly gross earnings that is exempt from any payment orders. DC-SC-6 (4/11) www.mass.gov/courts/districtcourt American LegalNet, Inc. www.FormsWorkFlow.com
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