Form Ri-9465 - Installment Agreement Request Page 2
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2State of Rhode Island and Providence Plantations
Form RI-9465
Installment Agreement Request
INCOME/EXPENSE STATEMENT
Column A
Column B
MONTHLY NET INCOME
Amount
MONTHLY EXPENSES
Amount
Wages/salaries
1
Rent
Wages/salaries (spouse)
2
Utilities
Other income (list sources):
3
Food
4
Medical
5
Insurance
6
Clothing
7
8
Other (list types):
9
10
11
12
13
14
Enter line 34: Total monthly installment payment
15
16
TOTAL MONTHLY INCOME
17
TOTAL MONTHLY EXPENSES
Column A Total Monthly Income Less Column B Total Monthly Expenses
BALANCE SHEET
Column A
Column B
Column C
ASSETS
Amount
LIABILITIES
Amount
Monthly Payment
Cash
18
Mortgage
Checking
19
Auto loans
Savings
20
Personal loans
Retirement accounts
21
Federal taxes due
Investments (Stocks, bonds)
22
State taxes due
23
Credit card(s)
TOTAL CURRENT ASSETS
24
25
Vehicle (Make, Year)
26
27
28
Other (list):
29
Real estate (address)
30
31
32
33
TOTAL ASSETS
34 TOTAL LIABILITIES
Page 2
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Parent category: Financial