Form Ftb 3561 - Installment Agreement Financial Statement - 2014 Page 4
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10. Do you expect changes to income or health that may change your monthly expenses? If yes,
explain:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
□
□
Have you filed bankruptcy?
Yes
No
If yes, complete the following:
District: __________________________________________________________________________________________
Case Number: ______________________________________________
Judge’s Name: ____________________________________________________________________________________
Petition Date: ____
/
____
/
______
Discharge Date: ____
/
____
/
______
Attorney’s Name: __________________________________________________________________________________
Attorney’s Telephone Number: ( ____ ) _____ – ________
FTB 3561 BKLT FILLABLE C2 (REV 07-2014) PAGE 5
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Parent category: Financial