Debtor Financial Statement Form - Bureau Of Revenue Services Page 4

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Section III.
Income and Expense Analysis
The following information applies to income and expenses
Accounting method used
during the period ________________ to _________________
Income
Expenses
27. Gross receipts from sales, services, etc. $
33. Materials purchased
$
28. Gross rental income
34. Net wages and salaries
29. Interest
35. Rent
30. Dividends
36. Installment payments
31. Other Income (specify)
37. Supplies
38. Utilities/Telephone
39. Gasoline/Oil
40. Repairs and maintenance
41. Insurance
42. Current taxes
43. Other (specify)
32. Total
$
44. Total
$
45. Net difference
$
46. Additional information (any information you feel might be pertinent)
Certification
Under the 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.
47. Signature
48. Title
49. Date
WAIVER
I authorize the Bureau of Revenue Services to obtain consumer reports or other information pertaining to my credit and financial
responsibility from and credit bureau, credit agency or consumer-reporting agency.
50. Your signature
51. Title
52. Date
Rev 6/01
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