Form Eg-13-I Financial And Other Information Statement For Individuals
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Illinois Department of Revenue
EG-13-I
Financial and Other Information Statement for Individuals
Note:
We may require support for amounts shown on this form.
Step 1: Tell us about yourself and your employment
Debtor’s information
Employment information
1
7
Your name ___________________________________________
Employer’s name _____________________________________
Street address ________________________________________
Address ____________________________________________
____________________________________________________
____________________________________________________
City
State
ZIP
City
State
ZIP
2
8
Email address ________________________________________
Work phone (_____)________________
9
3 Home phone (_____)________________
Length of employment _________________________________
4
Date of birth ___ ___/___ ___/___ ___ ___ ___
5
Social Security number
___ ___ ___ - ___ ___ - ___ ___ ___ ___
6
Number of dependents in household _______________________
Step 2: Tell us about other income and property.
Attach an additional sheet, if necessary.
10
Real property (brief description and location) ________________ _________________________________________________________
______________________________________________________ _______________________________________________________
______________________________________________________ _______________________________________________________
11
List the name and address of the banks where you have accounts.
Name_______________________________________________
Name_______________________________________________
Address _____________________________________________
Address _____________________________________________
____________________________________________________
____________________________________________________
City
State
ZIP
City
State
ZIP
Name_______________________________________________
Name_______________________________________________
Address _____________________________________________
Address _____________________________________________
____________________________________________________
____________________________________________________
City
State
ZIP
City
State
ZIP
12
Vehicle license number ____
_________________________________________________________________________________________________
Vehicle description _____________________________________________________________________________________________
Step 3: Tell us if bankruptcy is pending
13
Are foreclosure, bankruptcy, receivership, or assignment for benefit of creditors proceedings pending? ____yes ____no
14
Bankruptcy number ____________________________________
15
Date filed ___ ___/___ ____/___ ___ ___ ___
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EG-13-I front (R-5/12)
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Parent category: Financial