Form Ftb 3561 - Installment Agreement Financial Statement - 2014
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5State of California – Franchise Tax Board
Installment Agreement Financial Statement
Please furnish the information requested on this form. It is important that all questions are answered. If you run out of
space, please attach additional pages (write your name and social security number on all additional pages). All information
will be verified.
1. Taxpayer Information
Name
Home Telephone Number
Work Telephone Number
(
)
–
(
)
–
Address
Spouse’s Work Phone Number
Personal Fax Number
(
)
–
(
)
–
Taxpayer’s Social Security Number
Spouse’s Social Security Number
–
–
–
–
City, State, ZIP
Taxpayer’s Date of Birth
Spouse’s Date of Birth
/
/
/
/
2. List all dependents and non-relatives living with you
Name
Age
Relationship
Name
Age
Relationship
3. Employment Information
Taxpayer
Spouse
Employer/
Employer/
Business Name: _______________________________________
Business Name: ______________________________________
Address: _____________________________________________
Address: ____________________________________________
City, State, ZIP: ________________________________________
City, State, ZIP: _______________________________________
Employer/Business Tel Number: (
)
– _____________
Employer/Business Tel Number: (
)
– ____________
Employer/Business Fax Number: (
)
– ____________
Employer/Business Fax Number: (
)
– ___________
Occupation/Profession: __________________________________
Occupation/Profession: _________________________________
How long employed: ____________________________________
How long employed: ___________________________________
Marital Status on your W-4: _______________________________
Marital Status on your W-4: ______________________________
Number of exemptions you claim: __________________________
Number of exemptions you claim: _________________________
FTB 3561 BKLT FILLABLE C2 (REV 07-2014) PAGE 2
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Parent category: Financial