Clear Form
STATEMENT OF FINANCIAL
FOR REVENUE USE ONLY
O R E G O N
Date Received
CONDITION FOR INDIVIDUALS
D E PA R T M E N T
O F R E V E N U E
Revenue Agent
Reference No. ____________________________________
Prog
Social Security No.
Year
Period
Liability
Code
Return By
• Please complete both sides of this form.
Your Name and Spouse’s Name
Your Birth Date
Spouse’s Birth Date
Street Address (and post office box, if applicable)
Your Social Security Number
Spouse’s Social Security Number
City
State
ZIP Code
Your Driver’s License Number/State
Spouse’s Driver’s License Number/State
Telephone Numbers—
Home Phone
Cell Phone
Your Work Phone
Spouse’s Work Phone
Age and Relationship of Dependents Who Live with You
Circle Best Daytime
Telephone Number
Name of Your Employer or Business
Exemptions
Exemptions
Name of Spouse’s Employer or Business
Claimed
Claimed
Address
Address
Date Hired
Pay Days
Date Hired
Pay Days
Job Title
Job Title
BANK ACCOUNTS— Include accounts in savings and loans and credit unions, certificates of deposit, individual retirement accounts (IRAs), and funds
held in safe deposit boxes.
Type of Account
Name of Institution
Branch
Account Number
Balance
(Checking/Savings)
CREDIT CARDS, LOANS, LINES OF CREDIT
Minimum
Name of Credit Card/Bank
Address and Telephone Number
Credit Limit
Amount Owed
Monthly Payment
REAL ESTATE
Current
Mortgage
Unpaid
Name and Telephone Number of
Address (including county)
Assessed Value
Balance
Property Tax
Person/Bank That You Pay
MOTOR VEHICLES— List additional vehicles on a separate sheet.
Date Loan
Name and Telephone Number of
Year/Make/License Number/State
Will Be Paid
Loan Balance
Person/Bank That You Pay
OTHER ASSETS YOU OWN OR ARE CURRENTLY BUYING—Include stocks, bonds, boats, etc.
Name and Telephone Number of
Description
Current Value
Loan Balance
Person/Bank That You Pay
150-860-009 (Rev. 2-05) Web
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