Financial Statement - Individuals
Financial Information Statement for Individuals(if you need additional space, please attach a separate sheet)92075000complete all blocks, except shaded areas. Write “N/A” (not applicable) in those blocks that do not applyFull name on DOR account: FORMTEXT ?????Registration Number (UBI) FORMTEXT ?????Section 1- Personal informationFull Name of Taxpayer and Spouse (if applicable) FORMTEXT ?????Home Phone FORMTEXT ?????Cell Phone FORMTEXT ?????Address (Street, City, State, ZIP, & County of Residence) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Business Phone FORMTEXT ?????Spouse’s Cell Phone FORMTEXT ?????Mailing Address (if different) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Marital Status: FORMCHECKBOX Married FORMCHECKBOX UnmarriedTaxpayer’s Email FORMTEXT ?????Spouse’s Email FORMTEXT ?????TaxpayerSocial Security No. (SSN)Date of Birth (mm/dd/yyyy)Other names or aliases FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Spouse FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Previous address(es) of Taxpayer FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Tax Year of last filed Federal Income Tax Return FORMTEXT ?????Number of exemptions claimed FORMTEXT ?????Gross Income$ FORMTEXT ?????Name, age and relationship of dependents living in your household (exclude yourself and spouse) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Section 2- Employment InformationTaxpayerSpouseEmployer Name FORMTEXT ?????Employer Name FORMTEXT ?????Employer Address FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Employer Address FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Work Phone FORMTEXT ?????Occupation FORMTEXT ?????Work Phone FORMTEXT ?????Occupation FORMTEXT ?????Pay Period: FORMCHECKBOX Weekly FORMCHECKBOX Bi-Weekly FORMCHECKBOX Monthly FORMCHECKBOX Other: FORMTEXT ?????How long employed:Pay Period: FORMCHECKBOX Weekly FORMCHECKBOX Bi-Weekly FORMCHECKBOX Monthly FORMCHECKBOX Other: FORMTEXT ?????How long employed:Years: FORMTEXT ?????Months: FORMTEXT ?????Years: FORMTEXT ?????Months: FORMTEXT ?????Section 3- Financial informationIs the individual or sole proprietorship party to a lawsuit (If yes, answer the following) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Plaintiff FORMCHECKBOX DefendantAmount of Suit $ FORMTEXT ?????Subject of Suit FORMTEXT ?????Possible Completion Date FORMTEXT ?????Has the individual or sole proprietorship ever filed bankruptcy (If yes, answer the following) FORMCHECKBOX Yes FORMCHECKBOX NoDate Filed/Filing AnticipatedDischarge/Closure DateBankruptcy Filing NumberType filedAny increase/decrease in income anticipated (business or personal) (If yes, answer the following) FORMCHECKBOX Yes FORMCHECKBOX NoExplain (use attachment if needed) FORMTEXT ?????How much will it increase/decrease?$ FORMTEXT ?????When will it increase/decrease? FORMTEXT ?????Is the individual or sole proprietorship a beneficiary of a trust, estate, or life insurance policy FORMCHECKBOX Yes FORMCHECKBOX No (If yes, answer the following) Name of the trust, estate, or policy FORMTEXT ?????Anticipated amount to be received FORMTEXT ?????$When will the amount be received FORMTEXT ?????Repossessions FORMCHECKBOX Yes FORMCHECKBOX NoIn the past 3 years have any assets been transferred by the individual for less than full value FORMCHECKBOX Yes FORMCHECKBOX NoList Asset FORMTEXT ?????Value at time of transfer$ FORMTEXT ?????Date Transferred FORMTEXT ?????To whom or where it transferred FORMTEXT ?????Personal Bank accounts (checking, online banking, money market accounts, savings, etc.)Type of AccountName and Address of Financial InstitutionAccount NumberBalance FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Amount of Cash on Hand$ FORMTEXT ?????Available Credit (Bank credit cards, Credit Unions, Savings & Loans, Lines of Credit) (attach additional sheets if needed)Type of Account or CardName and Address of Credit InstitutionCredit LimitAmount OwedCredit Available FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Investments (stocks, bonds, mutual funds, stock options, IRAs, 401K, Certificates of Deposit, government securities, GET accounts etc.)TypeName and Address of CompanyCurrent ValueLoan BalanceEquity (value minus loan) FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Real Property Owned, Rented, and Leased Attach additional sheets if neededProperty DescriptionPurchase/Lease DateCurrent Fair Market ValueCurrent Loan BalanceMonthly Payment AmountDate of Final PaymentEquity(Fair Market Value Minus Loan) FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMCHECKBOX Purchased FORMCHECKBOX LeasedLocation (Street, City, State, Zip & County) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Lender/Lessor/Landlord Name, Address, Phone FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Asset registered to: FORMTEXT ?????PropertyDescriptionPurchase/Lease DateCurrent Fair Market ValueCurrent Loan BalanceMonthly Payment AmountDate of Final PaymentEquity(Fair Market Value Minus Loan) FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMCHECKBOX Purchased FORMCHECKBOX LeasedLocation (Street, City, State, Zip & County) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Lender/Lessor/Landlord Name, Address, Phone FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Asset registered to: FORMTEXT ?????Personal Vehicles Leased & Purchased Include boats, RVs, motorcycles , and airplanes Attach additional sheets if neededDescription FORMTEXT ?????Purchase/Lease DateCurrent Fair Market ValueCurrent Loan BalanceMonthly Payment AmountDate of Final PaymentEquity(Fair Market Value Minus Loan) FORMCHECKBOX Purchased FORMCHECKBOX Leased FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Year FORMTEXT ?????Mileage FORMTEXT ?????License # FORMTEXT ?????Lender/Lessor/Landlord Name, Address & Phone FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Make FORMTEXT ?????Model FORMTEXT ?????Asset registered to: FORMTEXT ?????Description FORMTEXT ?????Purchase/Lease DateCurrent Fair Market ValueCurrent Loan BalanceMonthly Payment AmountDate of Final PaymentEquity(Fair Market Value Minus Loan) FORMCHECKBOX Purchased FORMCHECKBOX Leased FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Year FORMTEXT ?????Mileage FORMTEXT ?????License # FORMTEXT ?????Lender/Lessor/Landlord Name, Address & Phone FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Make FORMTEXT ?????Model FORMTEXT ?????Asset registered to: FORMTEXT ?????Personal Assets Include furniture, artwork, jewelry, coins, guns, antiques or other assets Attach additional sheets if neededDescription FORMTEXT ?????Purchase/Lease DateCurrent Fair Market ValueCurrent Loan BalanceMonthly Payment AmountDate of Final PaymentEquity(Fair Market Value Minus Loan) FORMCHECKBOX Purchased FORMCHECKBOX Leased FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Location (Street, City, State, Zip & County) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Lender/Lessor/Landlord Name, Address & Phone FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SECTION 4- Personal Income and Expense InformationMonthly Income/Expense StatementTotal IncomeTotal Living ExpensesSourceGross MonthlyExpense ItemsActual MonthlyWages (Taxpayer)$ FORMTEXT ?????Food, Clothing, and Misc.$ FORMTEXT ?????Wages (Spouse)$ FORMTEXT ?????Housing & Utilities$ FORMTEXT ?????Interest – Dividends$ FORMTEXT ?????Vehicle Ownership Costs$ FORMTEXT ?????Net Business Income$ FORMTEXT ?????Vehicle Operating Costs$ FORMTEXT ?????Net Rental Income$ FORMTEXT ?????Public Transportation$ FORMTEXT ?????Distributions$ FORMTEXT ?????Health Insurance$ FORMTEXT ?????Pension/Social Security (Taxpayer)$ FORMTEXT ?????Out of Pocket Healthcare Costs$ FORMTEXT ?????Pension/Social Security (Spouse)$ FORMTEXT ?????Court Ordered Payments$ FORMTEXT ?????Child Support$ FORMTEXT ?????Child/Dependent Care$ FORMTEXT ?????Alimony/Spousal Support$ FORMTEXT ?????Life Insurance$ FORMTEXT ?????Other (specify)$ FORMTEXT ?????Taxes (specify)$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Other (specify)$ FORMTEXT ?????Total Income$ FORMTEXT ?????Total Living Expenses$ FORMTEXT ?????Section 5- business informationBusiness informationBusiness Name (s) FORMTEXT ?????Type of Business FORMTEXT ?????Business Website FORMTEXT ?????Number of Employees: FORMTEXT ?????Payment ProcessorPayment Processor(First Data, PayPal, , Google Checkout, etc.)AddressPayment Processor Account Number FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Credit Cards Accepted by the BusinessCredit CardMerchant Account NumberMerchant Account Provider, Name & Address FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Business Bank Accounts (checking, online banking, money market accounts, savings, stored value cards, etc.)Type of AccountName and Address of Financial InstitutionAccount NumberBalance FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Amount of Cash on Hand$ FORMTEXT ?????Accounts/Notes receivable (Include all current contract jobs, loans to Family Members, loans to partners, etc.)You may attach Aged Receivable Report (Customer Balance Summary Report)NameAddress & PhoneAmount DueDue DateDays Past Due FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Do you currently factor receivables or use them as collateral for loans? FORMCHECKBOX Yes FORMCHECKBOX No If yes, complete the followingName of factor or lender FORMTEXT ?????Address FORMTEXT ?????Phone FORMTEXT ????? Business Assets (please specify) Attach additional sheets if neededDescription FORMTEXT ?????Purchase/Lease DateCurrent Fair Market ValueCurrent Loan BalanceMonthly Payment AmountDate of Final PaymentEquity(Fair Market Value Minus Loan) FORMCHECKBOX Purchased FORMCHECKBOX Leased FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Location (Street, City, State, Zip & County) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Lender/Lessor/Landlord Name, Address & Phone FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Description FORMTEXT ?????Purchase/Lease DateCurrent Fair Market ValueCurrent Loan BalanceMonthly Payment AmountDate of Final PaymentEquity(Fair Market Value Minus Loan) FORMCHECKBOX Purchased FORMCHECKBOX Leased FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Location (Street, City, State, Zip & County) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Lender/Lessor/Landlord Name, Address & Phone FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Tax LiabilitiesDate lien was filed or assessedCurrent Amount OwedMonthly Payment AmountDate first payment was madeName & Address of Lien/Note HolderIRS FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Labor & Industries FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Employment Security FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other Taxes Owed (specify) FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SECTION 5- Business Income and Expense Information You may attach Profit & Loss Report or Income Statement along with this sectionThe following information is based monthly income and expenses.Accounting Method Used: FORMCHECKBOX Accrual FORMCHECKBOX Cash(must be same as with IRS)Total Business IncomeTotal Business ExpensesSourceGross MonthlyExpense ItemsActual MonthlyGross Receipts$ FORMTEXT ?????Materials Purchased$ FORMTEXT ?????Gross Rental Income$ FORMTEXT ?????Inventory Purchased$ FORMTEXT ?????Interest$ FORMTEXT ?????Gross Wages & Salaries$ FORMTEXT ?????Dividends$ FORMTEXT ?????Rent$ FORMTEXT ?????Cash$ FORMTEXT ?????Supplies$ FORMTEXT ?????Other Income (specify below)$ FORMTEXT ?????Utilities/Telephone$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Vehicle Gasoline/Oil$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Repairs & Maintenance$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Insurance$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Current Taxes$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Notes or Loan Payments $ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Other (specify)$ FORMTEXT ?????Total Income$ FORMTEXT ?????Total Living Expenses$ FORMTEXT ?????Net Income (Income – Expenses)$ FORMTEXT ?????SECTION 6Please include the following documents with your financial statement: FORMCHECKBOX Copies of the last three month’s bank statements for the business FORMCHECKBOX Copies of the most recent business financial statements(including but not limited to balance sheets and profit and lost statements) should be submitted with this form. FORMCHECKBOX Attach a copy of all currently recorded UCC-1 financing statements on which the business is either a creditor or a debtor FORMCHECKBOX Each owner, partner, or office must disclose their name, address and the nature of any involvement or interest in other businesses. FORMCHECKBOX Other: FORMTEXT ?????Additional Comments and proposal for Electronic Partial Payment AgreementI am requesting to pay the total liability plus accrued penalties and interest in the following manner:$ FORMTEXT ?????To be paid (select one) FORMCHECKBOX Monthly FORMCHECKBOX Twice a Month FORMCHECKBOX Weekly Comments: FORMTEXT ?????If your payment terms are accepted, the payment amount you proposed will be withdrawn from your bank account electronically. Penalty and interest will accrue, as provided by law, until the balance is paid in full.Certification I declare that to the best of my knowledge and belief this statement of assets, liabilities, and other information is true, correct, and complete and I hereby authorize the Department of Revenue to verify the information contained herein as they deem necessary.Taxpayer SignaturePrint Taxpayer nameDate FORMTEXT ????? FORMTEXT ?????Taxpayer SignaturePrint Taxpayer nameDate FORMTEXT ????? FORMTEXT ????? ................
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