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Form 12a638 - Statement Of Financial Condition For Individuals - Revenue Cabinet Of Commonwealth Of Kentucky Page 2

Page 2

SECTION III—LIABILITIES

Type of Account

Name and Address of

Monthly

Credit

Amount

Credit

23. Other Liabilities

or Card

Financial Institution

Payment

Limit

Owed

Available

(include car payments,

judgments, notes and

other charge accounts)

24. Federal Taxes Owed

25. State Taxes Owed

SECTION IV—MONTHLY INCOME AND EXPENSE ANALYSIS

(a) Income

(b) Necessary Living Expenses

Source

Gross/Month

Net/Month

26. Wages/Salaries (taxpayer)

35. Rent/House Payment

27. Wages/Salaries (spouse)*

36. Groceries

37. Total Monthly Payment from

28. Interest—Dividends

Section III—Liabilities

29. Net Business Income

38. Utilities—Water, Electric,

(from Form 422-b)

Telephone, etc.

30. Rental Income

39. Insurance (monthly)

31. Pension (taxpayer)

a. Auto

Source:

b. Life

32. Pension (spouse)

c. Medical, etc.

source:

40. Monthly Medical Expenses

41. Estimated Tax Payments (only if you

33. Other

are currently making payments)

(federal-state)

42. Other Expenses (child support, etc.)

(specify)

43. TOTAL MONTHLY

34. TOTAL MONTHLY INCOME

LIVING EXPENSES

* Item 27 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 Revenue Cabinet to calculate household income and

44. Net Difference (income less necessary

expenses.

living expenses)

45. 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.

46. Your Signature

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

48. Date

Form 12a638 - Statement Of Financial Condition For Individuals - Revenue Cabinet Of Commonwealth Of Kentucky Page 2

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