96-029b 5/3/07 - Statement Of Financial Condition - Iowa Department Of Revenue Page 2
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1
2Item
Value
Item
Value
Boat, Motor, Trailer
Motorcycle/Quadrunner
Recreational Vehicle
Snowmobile
Tractor(s)
Home Furnishings
Other
Other
Life Insurance (cash value)
Life Insurance (cash value)
To Whom Paid
Payment
Balance
Credit Line
House Payment/Rent
Auto Loan
Auto Loan
Federal Tax
Internal Revenue Service (IRS)
MC/VISA
MC/Visa
Credit Card
Child Support/Alimony
(County)
Bank Loan
Other
Total Installments
$0.00
Monthly
Monthly Income Analysis
Source
Income
Wages
Total Income
$0.00
(include 2 recent stubs)
Spouse Wages
MINUS:
(include 2 recent stubs)
Rents/Contracts
Installment Payments
$0.00
Social Security
Groceries
Pensions
Utilities
Part-time Job
Insurance
Alimony
Car Expense
Public Assistance
Daycare
Child Support
Medical
Other (specify)
Other
NET DIFFERENCE
TOTAL
$0.00
$0.00
OTHER: Attach a separate sheet of paper for any other
IF REQUESTED, attach a refusal from your bank, savings and
information, such as expected changes in income, expenses,
loan, credit union, finance company for a loan of the outstanding
health, etc., or for any of the items shown above for which there
balance of your liability.
was insufficient room. Attach a separate sheet showing assets
SELF-EMPLOYED: Attach a copy of Schedule C or income and
transferred/sold/disposed of in the last 24 months or since the
expense reports for the last two years and a copy of the balance
liability was incurred, whichever is longer.
sheet for the business.
Under penalty of perjury, I declare that to the best of my knowledge and belief this statement of assets, liabilities and
other information is true, correct and complete. I also authorize the Iowa Department of Revenue to verify any information
shown on this statement.
_______________________________
__________
_______________________________
_________
Your signature
Date
Spouse’s signature
Date
96-029b (5/3/07)
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