Form 150-860-009 - Statement Of Financial Condition For Individuals - Oregon Department Of Revenue Page 2
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1
2This Column for
INCOME AND EXPENSES
Office Use Only
MONTHLY INCOME
Budgeted
Allowable
$
1. Your net pay. Attach two recent pay stubs..................................................................................................1
2. Spouse’s net pay. Attach two recent pay stubs ..........................................................................................2
3. Rent paid to you. Names and addresses of tenants _______________________________________ .......3
4. Income from other members of household ______________________________________________ .......4
5. Pensions (list source) ______________________________________________________________ .......5
6. Social Security ...............................................................................................................................................6
7. Profit from your business. Attach statement...................................................................................................7
8. Commissions..................................................................................................................................................8
9. Other Income. List source
(stocks, unemploy. benefits, profit sharing, alimony, child support)
_________________ .......9
$
10. TOTAL INCOME. Add lines 1 through 9.......................................................................................................10
Budgeted
Allowable
MONTHLY EXPENSES ACTUALLY PAID—Must be reasonable for size of family and location.
$
11. Mortgage/rent. State name and address of landlord ______________________________________ ..... 11
12. Alimony/child support ...................................................................................................................................12
13. Groceries, toiletries, etc. ........................................................ Number of people in household ______ .....13
14. Utilities—
a. Telephone ...........................................................................................................................14a
b. Electricity ............................................................................................................................14b
c. Heating–oil/natural gas....................................................................................................... 14c
d. Water/garbage....................................................................................................................14d
15. Transportation (gas, bus fares) .....................................................................................................................15
16. Insurance— a. Auto
............................................................................................................16a
Figure the monthly average for these .......................................................16b
b. Health/life
c. Homeowner/renter ............................................................................................................ 16c
17. Medical (doctors and medicine not paid by insurance) .......................................................................................17
18. Auto loans (total of installment payments per month) ........................................................................................18
19. Installment payments (per month). List name of store, bank, or credit card.
Balance Due
a. ___________________________________________________________
$ _______________ 19a
b. ___________________________________________________________
$ _______________ 19b
c. ___________________________________________________________
$ _______________ 19c
d. ___________________________________________________________
$ _______________ 19d
e. ___________________________________________________________
$ _______________ 19e
f. Federal (IRS) tax payments _____________________________________
$ _______________ 19f
g. Other (explain) ________________________________________________
$ _______________ 19g
$
20. Total monthly expenses. Add lines 11 through 19g ...................................................................................20
$
21. Disposable monthly income. Subtract line 20 from line 10 ..........................................................................21
$
22. Proposed monthly payment to Oregon Department of Revenue..............................................................22
23. What day of the month can you pay?...........................................................................................................23
ADDITIONAL INFORMATION—Expected changes to income or health, filed or anticipated bankruptcies, repossessions, etc.
Name and address of nearest relative
Telephone No.
Relationship
AUTHORIZATION TO DISCLOSE
Under penalties of perjury, I declare that this statement of assets, liabilities, and other information is true, correct, and complete. I/We
authorize the Oregon Department of Revenue to verify any information on this financial statement.
Your signature
Date
Spouse’s signature (if joint return was filed)
Date
X
X
150-860-009 (Rev. 2-05) Web
Return this form to: OREGON DEPARTMENT OF REVENUE
PO BOX 14725
SALEM OR 97309-5018
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