Form Ftb 3561 - Installment Agreement Financial Statement - 2014 Page 3
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59b. Monthly Income and Expenses (Expense must be reasonable for the size of your family, location,
and circumstances).
Monthly Expenses
Item
Amount
FTB Use Only
□
$
Homeowner
Enter Monthly mortgage payment
E
□
$
Renter
Enter Monthly rent payment
E
Payments made to: ______________________________________________________
______________________________________________________
Address:
______________________________________________________
______________________________________________________
City/State/ZIP:
______________________________________________________
Telephone Number: (_____) _____ - ________
Alimony/Child Support (If payroll deduction, do not enter)
$
Groceries
$
Childcare/Daycare
$
Utilities:
$
Electricity
Heat
$
$
Water
Sewer
$
$
Telephone
Transportation (Number of miles to and from work ________ )
$
$
Doctor and medical bills not paid by insurance
Insurance (not paid through payroll deductions):
Vehicle
$
$
Health
Life
$
$
Homeowners/Renters
IRS Installment Agreement – (Total Amount Due $______________________)
$
Quarterly Estimate Income Tax Payments
Federal
$
$
State
Vehicle Payments (List Lien Holder below)
1.
$
2.
$
3.
$
Credit Obligations
Available
Minimum
Name of Creditor/Card
Credit Limit
Amount Owed Cash Advance Monthly Payment
1.
$
$
$
$
2
$
$
$
$
.
3
$
$
$
$
.
4
$
$
$
$
.
5
$
$
$
$
.
6
$
$
$
$
.
7
$
$
$
$
.
AMOUNT
Other Expenses (List all other personal obligations not
included above)
1
$
.
2
$
.
3
$
.
$
Total Monthly Expenses E
0.00
Monthly Payment Proposal E
(Begin making payments NOW. You will be notified of our decision.)
$
FTB 3561 BKLT FILLABLE C2 (REV 07-2014) PAGE 4
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Parent category: Financial