Form 12a638 - Statement Of Financial Condition For Individuals July 2004 (Page 2 of 2) in pdf

Form 12a638 - Statement Of Financial Condition For Individuals July 2004 Page 2

12A638 (7-04)

Page 2

SECTION III—LIABILITIES

Type of Account

Name and Address of

Monthly

Credit

Amount

Credit

24. Other Liabilities

or Card

Financial Institution

Payment

Limit

Owed

Available

(include car payments,

judgments, notes and

other charge accounts)

25. Federal Taxes Owed

26. Other Taxes Owed

SECTION IV—MONTHLY INCOME AND EXPENSE ANALYSIS

(a) Income

(b) Necessary Living Expenses

Source

Gross/Month

Net/Month

27. Wages/Salaries (taxpayer)

36. Rent/House Payment

28. Wages/Salaries (spouse)*

37. Groceries

38. Total Monthly Payment from

29. Interest—Dividends

Section III—Liabilities

30. Net Business Income

39. Utilities—Water, Electric,

(from Form 433 B)

Telephone, etc.

31. Rental Income

40. Insurance (monthly)

32. Pension (taxpayer)

a. Auto

Source:

b. Life

33. Pension (spouse)

c. Medical, etc.

Source:

41. Monthly Medical Expenses

42. Estimated Tax Payments (only if you

34. Other

are currently making payments)

(federal-state)

43. Other Expenses (child support, etc.)

(specify)

44. TOTAL MONTHLY

35. TOTAL MONTHLY INCOME

LIVING EXPENSES

* Item 28 should be completed if you are married even if your spouse is not liable for the tax. This

information is necessary in order for the Department of Revenue to calculate household income and 45. Net Difference (income less necessary

expenses.

living expenses)

46. Additional Information (Court proceedings, bankruptcies, repossessions, recent transfers of assets for less than full value, anticipated increases in income, condition of

health, etc.) Include information on trusts, estates, profit-sharing plans, etc., on which you are a participant or beneficiary.

CERTIFICATION—Under penalties of perjury, I declare that to the best of my knowledge and belief, this statement of assets, liabilities and

other information is true, correct and complete.

47. Your Signature

48. Spouse’s Signature (if joint return was filed)

49. Date

Form 12a638 - Statement Of Financial Condition For Individuals July 2004 Page 2

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