State Tax Form 99 - Financial Hardship Fiscal Year - Application For Property Tax Deferral Page 3
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4E. FINANCIAL STATEMENT. Complete this section fully. Copies of your federal and state tax returns and other
documentation may be requested to verify your income and assets.
ASSETS
LIABILITIES
REAL ESTATE
Domicile value
$
Mortgage outstanding balance
$
Other value
PERSONAL ESTATE
Motor vehicle values
(year/make/model)
Car loan balances
Bank account balances
(Bank name & address)
Other
Other outstanding debts
(specify)
(personal loans, credit
cards, etc.)
TOTAL
$
TOTAL
$
Monthly
Monthly
INCOME
EXPENSES
Wages & salaries -Annual $
$
Mortgage payments (including taxes) ........$
Unemployment compensation...................
Food ...................................................................
Social Security ..............................................
Utilities:
Other pension/retirement ..........................
Electricity .....................................................
Public assistance:
Gas ................................................................
AFDC ........................................................
Heating fuel .................................................
Food stamps.............................................
Telephone ....................................................
Fuel assistance .........................................
Water/sewer ...............................................
Other .........................................................
Debt payments:
Rental income ...............................................
Car loans ......................................................
Business/professional profits ....................
Credit cards .................................................
Interest/dividends.......................................
Personal loans .............................................
Other
Fixed expenses:
(specify)
Car insurance ..............................................
House insurance .........................................
Other
(specify)
TOTAL
$
TOTAL
$
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