Statement Of Financial Condition For Individuals Form 2005 Page 3

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SECTION V – INCOME AND EXPENSE ANALYSIS
(a) Income
(b) Necessary Living Expenses
47. Rent/House payment
$
Source
Gross
Net
48. Groceries
$
49. Allowable installment
(Taxpayer)
39. Wage/Salary
$
$
$
Payments
(Spouse)
40. Wages/Salary
50. Utilities
$
41. Interest - Dividends
51. Transportation
$
42. Net Business Income
52. Insurance
$
(from Form REV-484 or REV-488)
43. Rental Income
53. Medical
$
(Taxpayer)
44. Pension
54. Estimated tax payments
$
(federal-state)
Source:
(Spouse)
45. Pension
(specify)
55. Other expenses
$
Source:
46. TOTAL
$
$
56. TOTAL
$
(income less
Item 40 should be completed if you are married even if your spouse is not liable for
57. Net difference
$
necessary living expenses)
the tax. This information is necessary in order for the Department of Revenue to
calculate household income and expenses.
CERTIFICATION – Under penalties of perjury, I declare that to the best of my knowledge and belief this statement of assets, liabilities and other infor-
mation is true, correct and complete.
58. Your Signature
59. Spouse, Attorney or Accountant Signature (POA Attached)
60. Date
– Page 3 –

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