Form Ftb 3561 - Installment Agreement Financial Statement - 2014 Page 2
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54. Bank Accounts (Includes Savings & Loans, Credit Unions, IRA’s)
Type of Account
(Checking/Savings)
Name of Institution
Address
(Joint/Separate)
Account Number
Balance
$
$
$
$
Total E
0.00
5. Real Estate
Date
Current
Mortgage
Address/County of Property
Purchased
Value
Balance
Paid to: (Lender Name)
/
/
$
$
/
/
$
$
/
/
$
$
$
$
Total E
0.00
0.00
6. Motor Vehicles
Date
Current
Year, Make, and License Number
Purchased
Value
Loan Balance
Date Loan Will Be Paid Off
/
/
$
$
/
/
/
/
$
$
/
/
/
/
$
$
/
/
Total E
$
$
0.00
0.00
7. Life Insurance
Amount You Can
Amount You Can
Name of Company
Borrow on Policy
Name of Company
Borrow on Policy
$
$
8. Other Assets (Stocks, Bonds, Boats, etc.)
Description
Current Value
Loan Balance
Date Loan Will Be Paid Off
$
$
/
/
$
$
/
/
$
$
/
/
$
$
/
/
$
$
Total E
0.00
0.00
9a. Monthly Income and Expenses (Based on all members of the household)
Monthly Income
Item
Amount
FTB Use Only
Net Pay (amount you take home from wages and/or self employment)
$
Spouses Net pay (amount spouse takes home from wages and/or self employment.
If self employed, see Page 6
$
Rents Received
$
$
Pensions
$
Disability/Social Security
$
Commissions
$
Other Income:
$
Dividends
Interest
$
Child Support
$
Royalties
$
Alimony
$
Other (list) _______________________________________________
$
Income contributed from other people living in your home
$
$
Total Monthly Income E
0.00
FTB 3561 BKLT FILLABLE C2 (REV 07-2014) PAGE 3
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