Form Ro-1062 - Collection Information Statement For Individuals Page 4
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622.
23.
24.
25.
Number in Household
# Cars
# Car Loans
County
Section 10.
Monthly Income and Expense Analysis
INCOME
Source
Net
26. Wages/ Salaries ( Taxpayer) * Attach copy of most recent pay stub
27. Wages/Salaries (Spouse) * Attach copy of most recent pay stub
28. Rent paid to taxpayer
29. Other members of household
30. Pension(s)
31. Social Security
32. Profit from Business
33. Commissions
34. Other Income
35. Total Income
NECESSARY LIVING EXPENSES
Source
Amount
Source
Amount
36. Mortgage/Rent
42. Auto loans
37. Utilities
43. Health/Life Insurance
A. Telephone/Cell
44. Medical
B. Electricity
45. IRS Tax Payments
C. Heating
46. Miscellaneous Payments
D. Water/Garbage
A. Child Support
38. Homeowner/renter insurance
B. Alimony
39. Groceries
C. Daycare
40. Gas/Maintenance, etc.
D. Estimated tax
47. Total Expenses
41. Auto Insurance
Calculated Disposable Income (total income less total expenses)
Expenses not generally allowed: We generally do not allow tuition for private schools, public or private college expenses, charitable
contributions, voluntary retirement contributions, payments on unsecured debts such as credit card bills, cable television and other similar
expenses. However, we may allow these expenses if it is proven that they are necessary for the health and welfare of the individual or family
or for the production of income.
Under penalties 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.
Certification
Your signature
Spouse's signature (if joint return was filed)
Date
Attachments Required for Wage Earners and Self-Employed Individuals:
Copies of the following items for the last 3 months from the date this form is submitted. (check all the attached items)
Income- Earnings statements, pay stubs, etc. from each employer, pension/social security/other income, self employment income
(commissions, invoices, sales, records, etc. and business financial statement if self-employed.)
Banks, Investments, and Life Insurance - Statements for all money market, brokerage, checking and savings accounts, certificates
of deposit, IRA, stocks/bonds, and life insurance policies with a cash value.
Assets - Statements from lenders on loans, monthly payments, payoffs, and balances for all personal and business assets. Include
copies of UCC financing statements and accountant's depreciation schedules.
Expenses - Bills or statements for monthly recurring expenses of utilities, rent, insurance, property taxes, phone and cell phone,
insurance premiums, court orders requiring payments (child support, alimony, etc.), other out of pocket expenses.
Other - credit card statements, profit and loss statements, all loan payoffs, etc.
A copy of last year's Form 1040 with all attachments. Include all Schedules K-1 from Form 1120S or Form 1065, as applicable.
Form RO-1062 page 4 (Rev. 4-10)
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